A nurse is caring for four clients. Which of the following clients should the nurse assess first?

A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness

A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL

A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10

A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Answer and Explanation

The Correct Answer is A

a.   The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b.   While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c.   Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d.   The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.

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Correct Answer is B

Explanation

a. Advising the newly licensed nurse to complete less time-consuming tasks first may not address the underlying issue of difficulty focusing and prioritizing care effectively.
b. Recommending that the newly licensed nurse take time to plan at the beginning of his shift can help him organize tasks and prioritize care more effectively.
c. While offering to provide care for his clients while he takes a break is supportive, it does not address the underlying issue of difficulty focusing and prioritizing care.
d. Asking other staff members to take over some of his tasks may be necessary in some situations but should not be the first intervention. Helping the nurse develop strategies to improve focus and organization is more appropriate.

A. Include the time the medication error occurs in the report B. Make a copy of the incident report for personal record-keeping C. Identify the medication name and dosage administered to the client in the report D. Place a copy of the completed report in the client's medical record E. Obtain an order from the client's provider to complete the report

Correct Answer is ["A","C"]

Explanation

a. Including the time the medication error occurred is important for accurately documenting the sequence of events and providing context for further investigation or review.
b. Making a copy of the incident report for personal record-keeping may not be necessary as the incident report is typically filed in the institution's records system.
c. Identifying the medication name and dosage administered to the client is essential for understanding the nature and severity of the medication error and guiding subsequent actions or interventions.
d. Placing a copy of the completed report in the client's medical record, which is inappropriate because incident reports are internal documents and not part of the client's health record.
e. Obtaining an order from the client's provider to complete the report may not be necessary as incident reporting is typically a standard practice and does not require provider authorization.

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A nurse is caring for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?

Correct Answer is B

Explanation

26) a nurse is preparing to complete an incident report regarding a medication error which of the following actions should the nurse plan to take? select all that apply

Correct Answer is ["A","C"]

Explanation

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