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 B

Explanation

Choice A rationale: While a history of vomiting at home for 3 days prior to surgery may be relevant, the information provided by the PACU nurse already includes the time of the last administration of nausea medications, making this option less critical at this moment.

Choice B rationale: Providing information about the abdomen, bowel sounds, and the absence of bleeding on the dressing is essential for assessing the postoperative condition of the client. It gives the receiving nurse a comprehensive overview of the client's immediate status following surgery.

Choice C rationale: Refusal to take ice chips for complaints of dry mouth is relevant to the client's comfort and hydration but may not be as critical as assessing surgical outcomes and complications.

Choice D rationale: Information about peripheral pulses and the range of motion of both legs is important but may be more pertinent to the neurological and circulatory assessment rather than immediate postoperative concerns. The surgical site and abdominal assessment are more directly related to the recent laparotomy.

A. Advise the staff nurse to remove the restraints from the client's wrists. B. Determine the client has a PRN prescription for an antianxiety agent. C. Contact the healthcare provider to ensure that a prescription for restraints was written. D. Close the door to the room to avoid disturbing other clients in nearby rooms.

Correct Answer is A

Explanation

Choice A rationale: The priority is to ensure the client's safety and comfort. If the client is restrained for bed linen change, alternative methods that don't involve wrist restraints should be considered. The nurse manager should advise the staff nurse to remove the restraints promptly.

Choice B rationale: Determining whether the client has a PRN prescription for an antianxiety agent is not the priority in this situation. The immediate concern is the use of restraints for a non-emergency purpose.

Choice C rationale: Contacting the healthcare provider to ensure a prescription for restraints was written may be needed, but the immediate concern is addressing the use of restraints for changing bed linens.

Choice D rationale: Closing the door to the room to avoid disturbing other clients is not the priority in this situation. The primary concern is the use of restraints for a non emergency purpose.

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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)]

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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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)]