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?

The child has red fissures at the corners of the mouth.

The child has several small bruises on both legs.

The child sleeps for about 13 hours each night.

The child is not regularly attending school.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

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Correct Answer is B

Explanation

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.

A. Assist clients who are in immediate danger to a safe location. B. Close doors and windows on the unit. C. Attempt to extinguish the fire using an ABC fire extinguisher. D. Discontinue oxygen use for clients who can breathe without it.

Correct Answer is A

Explanation

Choice A rationale:

The nurse's first priority in the event of a fire is the safety and well-being of the clients. Clients who are in immediate danger due to the fire should be assisted to a safe location as quickly as possible. This choice is supported by the principles of prioritizing client safety during emergencies.

Choice B rationale:

Closing doors and windows on the unit is a secondary action and comes after ensuring the safety of clients in immediate danger. While it can help contain the fire's spread, it should not be the nurse's first action, as it does not address the immediate risk to clients' lives.

Choice C rationale:

Attempting to extinguish the fire using an ABC fire extinguisher might be a consideration in emergency situations; however, the nurse's first responsibility is to ensure the safety of clients. The nurse should not put themselves or clients at risk by attempting to extinguish the fire before moving clients to safety.

Choice D rationale:

Discontinuing oxygen use for clients who can breathe without it is not the nurse's primary action during a fire emergency. While it's important to manage resources, such as oxygen, the immediate focus should be on evacuating clients from the danger zone.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

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

Correct Answer is A

Explanation

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?

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A nurse manager needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing this issue?

A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take?

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A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?