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 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.

A. Complete an incident report. B. Evaluate the client for injury. C. Notify the nurse manager. D. Report the error to the provider.

Correct Answer is B

Explanation

A. Complete an incident report:
This is an important step for documentation and risk management but should be done after assessing for possible client harm.

B. Evaluate the client for injury:
The nurse’s first responsibility after discovering an error is to assess the client’s condition to ensure safety and identify any adverse effects (priority: client safety).

C. Notify the nurse manager:
This is appropriate after assessing the client, but not the immediate first step.

D. Report the error to the provider:
This should be done after assessing the client so the provider can be informed of the client’s current status and any necessary interventions.

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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

A nurse is receiving change-of-shift report about four clients. Which of the following clients should the nurse ask the charge nurse to reassign to an RN?

Correct Answer is A

Explanation

A staff nurse discovers a treatment error made by a nurse on the previous shift. The staff nurse finds no documentation of the error. Which of the following actions should the staff nurse take first?

Correct Answer is B

Explanation

A nurse is preparing to administer a medication to a client and discovers that the incorrect dose of medication was administered during the previous shift. Which of the following actions should the nurse take first?

A nurse overhears an assistive personnel (AP) tell a client, "If you don't eat more, the staff will insert a feeding tube." The nurse should explain to the AP that this statement is an example of which of the following torts?

A nurse is documenting the care of a client in the computer when she is called to another client's room. Which of the following actions should the nurse take?

A nurse is observing an assistive personnel (AP) complete perineal care for a female client who has an indwelling urinary catheter. For which of the following actions by the AP should the nurse intervene?

A nurse is caring for a client who has type 1 diabetes mellitus. Which of following actions should the nurse take first when providing morning care?

A nurse on a medical-surgical unit is assisting with the review of the electronic medical record for a group of clients during a mass casualty event. Exhibits Select the 2 clients the nurse should recommend for discharge to make room for clients injured in the disaster.

A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?

A nurse working in a provider's office is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?