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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.

A. Autonomy B. Fidelity C. Beneficence D. Justice

Correct Answer is A

Explanation

A. Autonomy refers to the right of individuals to make their own decisions regarding their healthcare, including the right to refuse treatment, which the nurse has supported in their response.
B. Fidelity involves being faithful to commitments made to patients, such as providing care and support, but does not directly pertain to the client's right to refuse treatment.
C. Beneficence focuses on promoting the well-being of the client, which may not align with the client’s decision to refuse treatment in this context.
D. Justice refers to fairness in healthcare and ensuring equitable treatment, but it does not address the specific right of the client to refuse treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a dressing change for a client who has a nondraining, stage III pressure ulcer that is infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a terminal illness and states that they wish to discontinue their enteral feedings. The nurse responds by saying, "You have a right to refuse treatment." This response by the nurse demonstrates which of the following ethical principles?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following information should the nurse include?

A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

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 nurse is assisting with the development of an in-service about client advocacy. Which of the following information should the nurse include when describing advocacy?

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?

A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?

A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?