A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.
Which of the following clients should the nurse instruct the AP to report to the nurse?

A client who has a prescription for compression stockings and did not receive them.

A client who consumes all the food from their meal tray.

A client who requests to sit in the bedside chair while watching TV.

A client who requests assistance to use the bedside commode.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should instruct the assistive personnel (AP) to report the client who has a prescription for compression stockings but did not receive them. This situation involves a missed intervention that is crucial for the client's health and safety. Reporting this to the nurse allows timely intervention and ensures that the client receives the necessary care.

Choice B rationale:

Consuming all the food from the meal tray is not a cause for concern and does not require immediate reporting to the nurse. It is a normal behavior and does not indicate any potential issues with the client's health or safety.

Choice C rationale:

The client's request to sit in the bedside chair while watching TV is a common and appropriate request. It does not pose any risk to the client's health or safety and does not require immediate reporting to the nurse.

Choice D rationale:

A client requesting assistance to use the bedside commode indicates a need for assistance with a basic activity of daily living. The AP should assist the client with this request as appropriate and does not need to report it to the nurse unless complications or concerns arise during the process.

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Correct Answer is A

Explanation

Answer is: a. "The estimated blood loss was 250 milliliters."

Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.

Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.

Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.

Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.

A. Give the client protamine if signs of magnesium sulfate toxicity occur. B. Monitor the FHR via Doppler every 30 min. C. Restrict the client's total fluid intake to 250 mL/hr. D. Measure the client's urine output every hour.

Correct Answer is D

Explanation

Choice A rationale:

Give the client protamine if signs of magnesium sulfate toxicity occur. Protamine is not the antidote for magnesium sulfate toxicity. Calcium gluconate or calcium chloride is used to counteract the effects of magnesium sulfate toxicity by antagonizing the action of magnesium on the neuromuscular junction and the heart.

Choice B rationale:

Monitor the FHR via Doppler every 30 min. While fetal heart rate (FHR) monitoring is important during magnesium sulfate infusion due to the risk of fetal distress, using Doppler every 30 minutes may not provide continuous and accurate monitoring. Continuous electronic fetal monitoring is the standard of care in this situation.

Choice C rationale:

Restrict the client's total fluid intake to 250 mL/hr. Magnesium sulfate is excreted by the kidneys, so maintaining adequate urine output is crucial to prevent magnesium toxicity. Restricting fluid intake to 250 mL/hr would likely reduce urine output, leading to an increased risk of magnesium sulfate accumulation in the body, which could be harmful.

Choice D rationale:

Measure the client's urine output every hour. Monitoring urine output is essential during magnesium sulfate infusion as it helps assess renal function and magnesium excretion. Adequate urine output (at least 30 mL/hr) is necessary to prevent magnesium toxicity. Therefore, measuring the client's urine output every hour is a critical nursing intervention to ensure the safety of the client.

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A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.Which of the following clients should the nurse instruct the AP to report to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is A

Explanation

A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

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A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.
Which of the following clients should the nurse instruct the AP to report to the nurse?