A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse see first?

A client who is scheduled for surgery and is having second thoughts after signing an informed consent

A newly admitted client who has type 2 diabetes mellitus and is refusing to eat their dinner

A client who is 1 day postoperative and has an increasing amount of serosanguineous drainage on the dressing

A client who has pneumonia, reports shortness of breath, and has an oxygen saturation of 88%

Answer and Explanation

The Correct Answer is D

Rationale:
A. A client who is having second thoughts about surgery requires support and clarification about informed consent, but this situation is not immediately life-threatening. The nurse can address this after more urgent needs are prioritized.

B. A client who is refusing dinner requires monitoring for blood glucose management, but this is not an immediate threat to life. The nurse can address dietary concerns after urgent clinical issues are managed.

C. Increasing serosanguineous drainage in a postoperative client is concerning for wound healing or early bleeding, but serosanguineous drainage is often expected postoperatively. The nurse should monitor the site and notify the provider if drainage continues to increase significantly, but it is less urgent than severe hypoxia.

D. A client with pneumonia, shortness of breath, and oxygen saturation of 88% is experiencing hypoxemia, which is a life-threatening condition requiring immediate intervention, such as supplemental oxygen and assessment for respiratory distress. According to ABC (Airway, Breathing, Circulation) prioritization, addressing impaired oxygenation takes precedence over other concerns.

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Correct Answer is D

Explanation

Rationale:

A. Measuring the size of a wound requires clinical judgment to accurately assess depth, length, width, and tissue characteristics. This task is within the registered nurse’s scope of practice and should not be delegated to an AP.

B. Collecting a wound culture is an invasive procedure that requires aseptic technique and clinical judgment to ensure accurate results and prevent infection. This task cannot be delegated to an AP.

C. Asking the client to describe their pain level involves assessment and documentation that requires nursing knowledge and judgment. The nurse must interpret the pain information and determine interventions.

D. Transporting the client for wound debridement is a non-invasive, routine task that does not require clinical judgment. An AP can safely assist the client in moving from the unit to the procedure area, ensuring mobility support and safety.

A. Request that the coworker complete an incident report. B. Submit an incident report to the risk manager C. File an anonymous report of the incident to the nurse manager D. Document a factual account of the incident. E. Identify all witnesses to the incident

Correct Answer is ["B","D","E"]

Explanation

Rationale:

A. Requesting that the coworker complete an incident report is inappropriate. The responsibility for reporting improper handling of controlled substances falls on the witness and the facility’s reporting system, not the person who committed the violation.

B. Submitting an incident report to the risk manager is correct. The risk manager ensures the incident is formally documented, reviewed, and addressed according to facility policy and regulatory requirements, preventing future errors and ensuring accountability.

C. Filing an anonymous report is not the preferred method. Reports should be factual, signed, and traceable to ensure proper follow-up, investigation, and legal compliance.

D. Documenting a factual account of the incident in objective terms is essential. Documentation should include what was observed, the time, date, and actions taken, avoiding opinions or assumptions.

E. Identifying all witnesses ensures a complete and accurate account of the incident. Witnesses can corroborate facts during investigation and support accountability.

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A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted for treatment of a wound. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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A nurse is teaching an in-service about the safe use of equipment to a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the teaching?

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