A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?

A client who has an abdominal wound and serosanguineous drainage

A client who had an open appendectomy 24 hr ago and reports a pain level of 5 on a scale from 0 to 10

A client who had a laminectomy 12 hr ago and reports numbness of the feet

A client who has COPD and an oxygen saturation level of 89%

Answer and Explanation

The Correct Answer is D

A. A client who has an abdominal wound and serosanguineous drainage:
This is expected in the early postoperative period unless drainage is excessive.

B. A client who had an open appendectomy 24 hr ago and reports a pain level of 5 on a scale from 0 to 10:
Pain should be addressed promptly, but it is not life-threatening and can be prioritized after more urgent issues.

C. A client who had a laminectomy 12 hr ago and reports numbness of the feet:
New numbness after spinal surgery could indicate nerve compression and needs urgent assessment, but airway and breathing take priority.

D. A client who has COPD and an oxygen saturation level of 89%:
An SpO₂ of 89% indicates hypoxemia, which is an airway/breathing issue and takes priority according to the ABCs.

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Correct Answer is C

Explanation

A. Contacting the recipient before faxing the information:
This is correct practice to ensure the right person receives the fax.

B. Shredding documents after faxing the information:
This is correct for protecting patient privacy and preventing unauthorized access.

C. Including critical lab values on the fax cover sheet:
The cover sheet should only contain minimal identifying information; critical medical details should not be on the cover sheet to maintain confidentiality.

D. Marking out client identifier information prior to faxing:
Removing identifiers is appropriate if the recipient does not require them for legitimate care purposes.

A. A client who requires initial education about blood glucose monitoring B. A client who requires an enteral feeding C. A client who requires tracheostomy suctioning D. A client who requires irrigation of an indwelling urinary catheter

Correct Answer is A

Explanation

A. A client who requires initial education about blood glucose monitoring:
Initial client teaching requires assessment, knowledge of the learning process, and evaluation - all of which are within the RN’s scope, not LPN or AP.

B. A client who requires an enteral feeding:
An LPN can safely administer an established enteral feeding, so this does not have to be reassigned to an RN.

C. A client who requires tracheostomy suctioning:
Tracheostomy suctioning of a stable patient is within the LPN’s scope of practice. Only unstable airway situations or assessment findings requiring intervention would necessitate an RN.

D. A client who requires irrigation of an indwelling urinary catheter:
LPNs are allowed to irrigate indwelling urinary catheters in most settings, so this task does not require RN reassignment.

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A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

Explanation

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