A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?

Reference Range:

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.

The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl (10.8 mmol/L).

The client with an Ileal conduit created two days ago with a scant amount of blood in the drainage pouch.

The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.

Answer and Explanation

The Correct Answer is D

Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.

Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.

Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.

Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.

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Correct Answer is D

Explanation

Choice A rationale: Paging a chaplain on call can be a supportive measure, but it might not address the immediate need for communication and coordination with the family.

Choice B rationale: Allowing each family member to ask a question one at a time may not be the most effective approach when dealing with multiple and repetitive questions.

Choice C rationale: Requesting the healthcare provider to speak with the family might be appropriate, but it could take time, and the immediate need is to establish effective communication.

Choice D rationale: Asking the family to identify a specific spokesperson helps streamline communication and ensures that information is conveyed more efficiently. This approach can help manage the situation and address the family's concerns collectively.

A. A 21-year-old with a history of a kidney transplant. Today the client reports "flu-like" symptoms with a fever of 100.4° F (38° C). B. A 42-year-old male who hurt his back while lifting yesterday. Today he has non radiating, low-back pain rated at 10 on a scale of 0 to 10. C. A client at 3-weeks gestation who today noted a small amount of bright red blood on the toilet paper after passing stool. D. A 2-year-old girl with a history of a "cold." Today she is tugging on her ear and has a fever of 102 F (38.9° C).

Correct Answer is D

Explanation

Choice A rationale: The client with a kidney transplant experiencing "flu-like" symptoms can be evaluated for urgency but may not require the first available appointment.
Choice B rationale: The client with non-radiating, low-back pain rated at 10 on a scale of 0 to 10 should be assessed, but it may not be an immediate concern compared to the other options.
Choice C rationale: The client at 3-weeks gestation with a small amount of bright red blood after passing stool requires evaluation, but it may not be as urgent as the client in Choice D.
Choice D rationale: The 2-year-old girl with a history of a "cold," tugging on her ear, and a fever of 102 F (38.9° C) may have an ear infection, which could be an acute problem requiring prompt evaluation.

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A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A nurse is performing telephone triage at the clinic office. Which client has the most acute problem and should be scheduled for the first available appointment?

Correct Answer is D

Explanation

A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

The nurse manager is encouraging the hospital nursing administrators to seek Magnet status for an acute care hospital. Which rationale should the nurse use to describe the greatest advantage of obtaining Magnet status?

During a 24-hour electronic health record review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the previous shift. Which immediate action is best for the nurse to take?

After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?

The charge nurse is providing instructions to an unlicensed assistive personnel (UAP) who will be assisting with the care of a client who has a hiatal hernia. Which instruction should the charge nurse provide the UAP?

The nurse manager conducts regular audits of patient care medication records and notices that the amount of narcotic pain medications administered during the evening shift on a postsurgical unit is higher than usual. Which action should the nurse manager take first?

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?

Reference Range:

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]