A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?
The client needs routine wound care performed.
The client develops a postoperative fever.
The client is experiencing a therapeutic effect from their treatment.
The client needs strict measurement of intake and output
The Correct Answer is B
A. The client needs routine wound care performed: Routine wound care is a stable, predictable task that can be delegated to assistive personnel. It does not require the judgment or assessment skills of a registered nurse.
B. The client develops a postoperative fever: A postoperative fever may indicate infection or another complication that requires assessment, clinical judgment, and possible intervention by a registered nurse. This warrants transfer of care to the RN for evaluation and appropriate action.
C. The client is experiencing a therapeutic effect from their treatment: Observing a therapeutic response is expected and does not necessitate RN-only care. Monitoring for ongoing effectiveness can be performed by other trained personnel as appropriate.
D. The client needs strict measurement of intake and output: While accurate intake and output monitoring is important, it is a routine, measurable task that can be delegated to assistive personnel. It does not require RN assessment unless abnormalities are noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,A,D,C
Explanation
A. Examine personal thoughts and feelings about meeting the client: The nurse should first engage in self-reflection to identify any biases, anxieties, or expectations. This helps ensure that personal feelings do not interfere with establishing a therapeutic and professional relationship with the client.
B. Introduce self and set goals for the relationship: After self-reflection, the nurse introduces themselves to the client and collaboratively establishes the goals and boundaries of the therapeutic relationship. This step builds trust and sets clear expectations for interactions.
C. Assist the client with identifying problem-solving techniques: Once the relationship is established, the nurse helps the client develop coping and problem-solving strategies. This step supports the client’s growth, autonomy, and ability to manage challenges effectively.
D. Summarize the achievement of goals that have been met: At the conclusion of the therapeutic relationship, the nurse reviews progress with the client and summarizes goals that were achieved. This reinforces accomplishments, encourages continued growth, and provides closure to the relationship.
Correct Answer is C
Explanation
A. Weight loss: Weight loss is more commonly associated with dehydration or inadequate nutritional intake. In fluid overload, clients typically demonstrate weight gain due to excess fluid retention.
B. Decreased skin turgor: Decreased skin turgor is a sign of fluid volume deficit rather than excess. Fluid overload usually presents with edema and taut skin rather than reduced elasticity.
C. Crackles heard in the lungs: Crackles indicate fluid accumulation in the alveoli and are a classic sign of fluid overload. This finding suggests pulmonary congestion and requires prompt assessment and intervention.
D. Decreased blood pressure: Fluid overload is more likely to cause increased or normal blood pressure due to expanded intravascular volume. Decreased blood pressure is more consistent with hypovolemia or shock states.
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