A nurse is assigned to care for four clients. Which client should the nurse assess first?

A postoperative client preparing for discharge with a new medication.

A client requiring daily dressing changes of a recent surgical incision.

A client scheduled for a chest x-ray after insertion of a nasogastric tube.

A client with asthma who requested a nebulizer treatment during the previous shift.

Answer and Explanation

The Correct Answer is D

Choice A reason: While it is important to prepare the postoperative client for discharge and ensure they understand how to take their new medication, this situation is less urgent than addressing a potential respiratory issue.

Choice B reason: Changing the dressing on a recent surgical incision is part of routine care and can be scheduled after more urgent needs are addressed. The client’s wound care is important, but it does not take precedence over potential respiratory distress.

Choice C reason: Although the chest x-ray is necessary to confirm the correct placement of the nasogastric tube, this can be done after the more immediate concern of a respiratory issue is addressed. The nasogastric tube will remain in place for feeding or drainage in the meantime.

Choice D reason: This client should be assessed first because asthma can lead to respiratory distress or an asthma attack, which requires prompt intervention. Since the client requested a nebulizer treatment during the previous shift, it is crucial to assess their current respiratory status and administer the treatment if necessary to prevent any complications.

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Correct Answer is C

Explanation

Choice A reason: Assigning tasks that were not completed to the next nursing shift is a part of shift change protocols but is not the primary responsibility after delegating tasks. Follow-up is crucial to ensure that all tasks are completed correctly and on time.

Choice B reason: Allowing each staff member to judge if the task needs to be completed undermines the importance of the tasks and could lead to inconsistencies in patient care. It is essential to follow up and ensure that the tasks are completed as delegated.

Choice C reason: Following up with each staff member regarding the performance and outcome of each task is critical. This ensures that the tasks are completed correctly, provides an opportunity to address any issues, and reinforces accountability in the team.

Choice D reason: Documenting that the task was completed is important, but it should occur after the nurse has confirmed that the task was performed correctly. Follow-up is essential to verify the accuracy and completeness of the delegated tasks before documentation.

A. Ability to prioritize B. Knowledge and skill to perform the task C. Rapport with clients D. Ability to complete the task without assistance

Correct Answer is B

Explanation

Choice A reason: The ability to prioritize is important for the overall management of tasks, but it is not the most critical factor when considering the delegation of specific tasks to assistive personnel.

Choice B reason: The knowledge and skill to perform the task is crucial when delegating tasks to assistive personnel. Ensuring that the AP has the appropriate training and competence to carry out the task safely and effectively is essential to maintaining high standards of care.

Choice C reason: Rapport with clients is important for building trust and effective communication, but it is secondary to having the necessary skills and knowledge to perform delegated tasks.

Choice D reason: While the ability to complete the task without assistance is beneficial, it is more important that the assistive personnel have the required knowledge and skills to perform the task correctly and safely.

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A nurse is assigned to care for four clients. Which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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