A nurse is caring for four clients. Which of the following assessment findings is the priority?

A client who has facial drooping following a stroke 8 hours ago.

A client who has a femur fracture and reports feeling short of breath.

A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10.

A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.

Choice A rationale:

A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.

Choice B rationale:

A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.

Choice C rationale:

A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.

Choice D rationale:

A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Determining the swallowing ability of a client who has had a stroke requires clinical judgment and assessment skills that fall within the scope of a registered nurse's practice. This task involves assessing potential risks and complications related to the client's condition.

Choice B rationale:

Providing an enteral feeding to a client who has Crohn's disease is within the scope of an LPN's practice. LPNs are trained to administer enteral feedings and manage stable clients with chronic conditions, such as Crohn's disease, under the supervision of a registered nurse.

Choice C rationale:

Developing a teaching plan for a client with a new diagnosis of type 2 diabetes mellitus involves comprehensive assessment, education, and planning. This task requires the expertise of a registered nurse, as it encompasses various aspects of disease management and requires tailored education based on individual client needs.

Choice D rationale:

Weighing a client who is 3 days postoperative following coronary artery bypass grafting involves monitoring for postoperative complications and assessing the client's stability. This task requires clinical judgment and the ability to recognize potential issues, making it more appropriate for a registered nurse to perform.

A. Take extra wheelchairs to the emergency department. B. Send PACU assistive personnel to assist with triage. C. Identify stable clients for transfer to a surgical unit. D. Report to the command center for further instructions.

Correct Answer is C

Explanation

The correct answer is C.

Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.

Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.

Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.

Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for four clients. Which of the following assessment findings is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)?

Correct Answer is B

Explanation

A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take?

Correct Answer is C

Explanation

A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first?

A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behaviors should the charge nurse identify as an indication that the staff nurse might be working while impaired?

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.).

A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following actions should the charge nurse take?