A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?
A client who has dementia and is experiencing paranoia
A client who has a UTI and reports itching after receiving a dose of cefaclor PO
A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr
A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III
The Correct Answer is B
A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While reviewing previous appraisals may provide some context, it is not the most effective way to evaluate current performance.
B. Gathering information from clients provides direct feedback about the AP’s performance and interactions, making it a valuable input for performance appraisals.
C. Examining the job description is helpful for understanding expectations, but it does not provide specific performance insights needed for an appraisal.
D. Peer reviews can be informative, but they may not reflect the full scope of the AP's duties and interactions with clients, which are critical for a comprehensive performance appraisal.
Correct Answer is C
Explanation
A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.
B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.
C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.
D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.
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