A nurse has received the assignment for the day shift.
After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?
A client with a fever who is diaphoretic and restless.
A postoperative client who has just received pain medication.
A client who is ambulatory.
A client scheduled for physical therapy at 1 pm.
The Correct Answer is A
Choice A rationale
Fever causes an increased metabolic rate, leading to diaphoresis and potential dehydration. Restlessness often signals early hypoxia or neurological changes that require immediate assessment to ensure airway and circulatory stability. In triage, the nurse must prioritize clients exhibiting signs of physiological distress or mental status changes. This client is the most unstable among the group, as restlessness can escalate to agitation or respiratory failure without prompt nursing intervention and cooling measures.
Choice B rationale
A postoperative client who has recently received pain medication is currently being managed for their primary concern. While pain is significant, it does not typically pose an immediate threat to life compared to restlessness and fever. The nurse should monitor for medication effectiveness and respiratory depression later, but since the intervention has already occurred, this client is considered stable. Immediate care is directed toward those with unaddressed acute symptoms rather than those in the recovery phase.
Choice C rationale
An ambulatory client is generally considered stable and able to perform activities of daily living with minimal assistance. Their ability to walk suggests that their cardiovascular and respiratory systems are compensated and not in acute distress. While they still require nursing assessment and care throughout the shift, they do not take priority over a client with systemic symptoms like fever and restlessness. Monitoring this client can be deferred until more urgent physiological needs are met.
Choice D rationale
A client scheduled for physical therapy later in the day, specifically at 1 pm, has a predictable and non-urgent schedule. This is a routine part of their rehabilitation process and does not indicate an acute change in status. Planning care around therapy sessions is a matter of time management rather than clinical prioritization. The nurse should focus on the most symptomatic and potentially unstable clients first to prevent complications before moving to routine appointments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This scenario specifically illustrates a failure to meet the established standard of care required of a reasonably prudent nurse. Since the medication label clearly indicated the correct amount, the nurse had a professional obligation to read and follow those instructions. Failing to do so constitutes a direct deviation from professional standards. In legal terms, this represents a breach because the nurse did not perform the duty that was expected within the clinical scope.
Choice B rationale
Causation refers to the direct link between the professional's negligent act and the resulting injury to the patient. While a dosage error could certainly lead to harm, this choice focuses on the outcome rather than the nature of the act itself. To prove causation, one must demonstrate that the error was the proximate cause of a specific physical or emotional injury. In this specific question, the act of the error is the primary focus, not the result.
Choice C rationale
Duty is the first element of malpractice and refers to the legal obligation of the nurse to provide care to the patient. It is established as soon as the nurse-patient relationship begins. While the nurse in this scenario certainly had a duty to the patient, the act of giving the wrong dose despite a clear label is the failure to fulfill that duty. Therefore, the situation is better described as a violation of the existing duty rather than duty itself.
Choice D rationale
Damages refer to the actual harm, injury, or loss suffered by the patient as a result of the malpractice. This can include physical pain, additional medical expenses, or lost wages. Without proof of damages, a malpractice claim cannot succeed even if a mistake was made. However, the question asks what the act of giving the wrong dosage represents, which is the functional failure of the professional, not the subsequent injury or loss the patient experienced.
Correct Answer is B
Explanation
Choice A rationale
Nursing science advances through both the generation of new knowledge and the application of that knowledge in clinical settings. Suggesting that translation is less important is scientifically inaccurate because research holds no clinical value if it is not applied to improve patient outcomes. Evidence-based practice bridges the gap between laboratory findings and bedside care. Both components are essential for a robust profession, and one cannot be deemed superior to the other.
Choice B rationale
Translation of research into practice, known as evidence-based practice, is the cornerstone of modern healthcare. It involves integrating the best available research evidence with clinical expertise and patient values. By adopting evidence-supported approaches, healthcare providers ensure that treatments are safe, effective, and efficient. This priority leads to standardized care protocols that reduce errors and improve the quality of life for patients, particularly in specialized environments like dementia care units.
Choice C rationale
While implementing research into practice involves challenges such as institutional resistance or lack of resources, claiming it is useless is a defeatist and unscientific perspective. Science relies on the iterative process of testing and application. Dismissing the effort to improve incontinence care through evidence prevents the advancement of nursing standards. Systematic barriers should be addressed through leadership and education rather than total abandonment of the process of clinical improvement.
Choice D rationale
A lack of knowledge regarding how to use evidence may be a barrier to implementation, but it does not characterize the translation of research itself. Translation is the process of movement from theory to action. Identifying a lack of knowledge is the first step in a needs assessment to facilitate better practice. This choice describes a hurdle rather than the inherent nature or value of applying research to solve clinical problems like incontinence.
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