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%.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Scheduling educational leave for all staff may be challenging and could disrupt the unit's operations.
Choice B rationale: Asking two staff members to attend and report what they learned to the unit's staff is a practical approach to disseminating the information without disrupting the entire staff.
Choice C rationale: Offering the program at three different times may still be challenging for staff with varying schedules, and it may not be the most efficient way to share the information.
Choice D rationale: Encouraging the education department to schedule the program at a convenient time is reasonable, but it may not guarantee that all staff can attend, and it may delay the dissemination of important information.
Correct Answer is D
Explanation
Choice A rationale: Asking the PN to change the sterile dressing while the nurse is busy may compromise patient safety and is not a prudent approach.
Choice B rationale: Reviewing the PN's skill checklist is important, but it may not provide immediate confirmation of the PN's competency in performing sterile wound care.
Choice C rationale: Telling the PN that past experience does not indicate the ability to perform skills may be discouraging and may not directly address the immediate need for a sterile dressing change.
Choice D rationale: Watching the PN perform sterile wound care to validate her skill level is the most direct and immediate way to ensure competency and patient safety.
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