A nurse is assisting in the care of clients on a postpartum unit. Which of the following events should the nurse identify as needing to initiate a security alert for?

An assistive personnel weighs and bathes the newborn in an empty client room

Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening

The caregiver and newborn have matching hospital identification bracelets

A hospital volunteer leaves the unit with the newborn to allow caregiver to rest

Answer and Explanation

The Correct Answer is D

A. An assistive personnel weighs and bathes the newborn in an empty client room: While this may not be ideal practice depending on facility policy, it does not necessarily indicate a security threat unless the newborn is removed from secured areas without authorization.

B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: It is common for nurses to transport newborns for necessary procedures, provided proper identification protocols are followed. This situation does not automatically trigger a security alert.

C. The caregiver and newborn have matching hospital identification bracelets: Matching ID bracelets are part of the standard safety protocol to ensure correct infant identification and prevent abduction. This situation demonstrates proper security measures.

D. A hospital volunteer leaves the unit with the newborn to allow the caregiver to rest: Volunteers are not authorized to transport newborns outside of secured areas. This action represents a serious breach of security and requires the immediate initiation of a security alert to prevent potential abduction or harm.

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Correct Answer is A

Explanation

A. Place the client in a room near the nurses' station: Clients with quadriplegia are at high risk for complications such as respiratory difficulties, pressure injuries, and autonomic dysreflexia. Placing them near the nurses’ station allows for closer monitoring and quicker response to any urgent needs.

B. Check on the client every 4 hr: Clients with quadriplegia require more frequent monitoring than every 4 hours. Regular repositioning, skin assessments, and prompt attention to needs must occur at much shorter intervals to prevent complications.

C. Place the call light within the client's reach: A client with quadriplegia typically has limited or no use of their upper extremities. Therefore, they would be unable to effectively use a standard call light and would need alternative methods, such as a specialized call device.

D. Place the client's glasses on the bedside table: If the client is unable to move their arms due to quadriplegia, placing glasses on the bedside table would not be useful. Necessary personal items should be made accessible through assistance or adaptive equipment.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

seizures: If a thyroid storm occurs, the client can experience seizures due to the extreme metabolic disturbances and nervous system overstimulation it causes. Seizures would be a serious complication indicating worsening neurological function. Therefore, the client’s risk for seizures is directly related to the risk of developing a thyroid storm after surgery.
paralytic ileus: Paralytic ileus involves bowel inactivity post-surgery, but the client had normoactive bowel sounds before surgery and no current documentation of absent or significantly reduced bowel activity. Therefore, this is not the most immediate risk based on current findings.
pneumonia: The client is receiving oxygen therapy and has a slightly increased respiratory rate after surgery, but no signs of labored breathing, abnormal lung sounds, or infection are reported. Although inactivity can contribute to pneumonia risk postoperatively, there are no current findings indicating that pneumonia is developing right now.
thyroid storm: The client had a thyroidectomy after presenting with signs of severe hyperthyroidism (weight loss, heat intolerance, anxiety, exophthalmos, goiter) and elevated T3 and T4 levels. Thyroid storm is a critical risk after thyroidectomy due to sudden hormone release, and it can cause life-threatening complications such as high fever, hypertension, tachycardia, and altered mental status.
bowel sounds: The bowel sounds were normal before surgery, and there is no mention of significant gastrointestinal changes postoperatively. Bowel sounds alone are not the critical factor leading to the client’s highest current risk.
inactivity: The client is currently lethargic after surgery and under the effects of anesthesia, which reduces movement and activity. Inactivity can cause decreased lung expansion and increase the risk of pulmonary complications like pneumonia. Although this is a concern, inactivity is not the client's most critical immediate risk compared to thyroid storm.

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A nurse is assisting in the care of clients on a postpartum unit. Which of the following events should the nurse identify as needing to initiate a security alert for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for ________ due to ________.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

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