A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?
A client who reports a severe migraine headache
A client who has a suspected diagnosis of tuberculosis (TB)
A client who sustained a head injury and is having periods of confusion
A client who has a history of atrial fibrillation and is on continuous ECG monitoring.
The Correct Answer is C
A. While a severe migraine headache is certainly uncomfortable and may require medication and observation, it does not typically necessitate constant monitoring. The client might benefit from a quieter room and can often be managed effectively with scheduled visits by nursing staff. Therefore, this client does not necessarily need to be closest to the nurses' station.
B. A client with a suspected diagnosis of TB should be placed in a negative-pressure isolation room to prevent the spread of airborne pathogens. The proximity to the nurses' station is less critical for infection control purposes. Proper isolation procedures and equipment are more important for managing TB.
C. A client with a head injury and periods of confusion is at risk for complications such as falls, disorientation, or worsening of their condition. This client requires close monitoring to ensure their safety and to promptly address any changes in their condition. Assigning this client to a room closest to the nurses' station ensures that the staff can frequently observe and quickly respond to any potential issues.
D. A client on continuous ECG monitoring requires regular assessment of their heart rhythm and immediate intervention if there are any abnormalities. While close monitoring is needed, this client’s condition is managed with electronic equipment that can alert staff to significant changes, so proximity to the nurses' station is less critical compared to more acute or unpredictable conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An educator's primary role is to provide knowledge and teach others about health-related topics, procedures, or skills. While analyzing a clinical situation might involve sharing information or educating patients and colleagues, the core function of an educator is to impart knowledge rather than solely analyzing clinical situations.
B. A mentor provides guidance, support, and advice based on their experience and expertise. While mentors might analyze clinical situations as part of their role, their primary focus is on guiding and developing others rather than just analyzing situations.
C. A critical thinker evaluates and interprets information, assessing situations logically and systematically to make sound decisions. Critical thinking is fundamental to effective problem-solving and decision- making in nursing practice.
D. An advocate supports and speaks up for the rights and needs of patients, ensuring their preferences and best interests are considered in care decisions.
Correct Answer is B
Explanation
A. While assisting others is an important aspect of nursing care, it generally does not directly reflect the acuity of clients. Assisting colleagues might involve helping with tasks, offering support, or collaborating on care, but it is more related to teamwork and overall unit dynamics rather than directly indicating the complexity or intensity of care needed by individual clients.
B. Medication administration is a significant factor in determining client acuity. The complexity and frequency of medications, the need for monitoring and adjustments, and the administration of high-risk medications (e.g., anticoagulants, insulin) all contribute to the overall acuity level. High acuity clients often require more complex medication management, which demands more time and attention from nursing staff.
C. Meal breaks are a necessary part of a nurse’s schedule but are not related to client acuity. Meal breaks are periods of rest and are essential for maintaining the nurse’s well-being and productivity. However, they do not affect the level of care required by clients or the determination of client acuity.
D. Charting is a crucial component of nursing care that reflects the time spent documenting client information, assessments, and care provided. While charting is essential for legal documentation, communication, and continuity of care, it is not a direct indicator of client acuity.
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