A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

A client who has pneumonia and has an axillary temperature of 38° C (101° F)

A client who has diarrhea and requests clear liquids for breakfast

A client who has a cast on the left leg and reports numbness and paresthesia

A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150

Answer and Explanation

The Correct Answer is C

Rationale:

A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.

B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.

C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.

D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.

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Correct Answer is A

Explanation

Rationale:

A. The physiologic status of the clients is the most critical factor in assigning tasks, ensuring that clients with more complex needs receive appropriate care.

B. Social relationships are secondary to patient safety and quality of care.

C. Personal comfort level should not influence assignment decisions; patient care needs are the priority.

D. Assigning the most experienced nurse to complex clients is appropriate, but it should be based on client needs rather than just experience alone.

A. Inform the staff member of her appraisal time for that day prior to change-of-shift report. B. Schedule the appraisal interview as early in the shift as possible. C. Provide the staff member with a copy of the appraisal form in advance. D. Provide a chair directly across the desk for the staff member to sit in.

Correct Answer is C

Explanation

Rationale:

A. Informing the staff member of her appraisal time for that day prior to change-of-shift report is not ideal as it may disrupt the shift handover process.

B. Scheduling the appraisal interview as early in the shift as possible might not be feasible or considerate, especially if it impacts patient care or the staff member's workflow.

C. Providing the staff member with a copy of the appraisal form in advance is best practice as it allows the staff member to prepare for the discussion and address any concerns or achievements.

D. Providing a chair directly across the desk for the staff member to sit in is not as important as preparing the staff member by sharing the appraisal criteria in advance.

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A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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