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 is experiencing a therapeutic effect from their treatment.

The client needs strict measurement of intake and output.

The client develops a postoperative fever.

The client needs routine wound care performed.

Answer and Explanation

The Correct Answer is C

Delegation and assignment of nursing care depend on client stability and the level of clinical judgment required. Postoperative clients may range from stable and predictable to unstable with potential complications requiring assessment and intervention by a registered nurse. A postoperative fever may indicate infection, inflammatory response, or more serious complications such as sepsis or atelectasis. Escalation to a higher level of nursing care is necessary when findings suggest potential clinical deterioration requiring advanced assessment and decision-making.

Rationale:
A. A client experiencing a therapeutic effect from treatment is considered stable and predictable. This indicates that the current plan of care is effective and no immediate escalation in nursing level is required. Such clients can typically continue to be managed within the current care assignment.

B. Strict measurement of intake and output is a routine, standardized nursing task that can be delegated appropriately depending on facility policy and client stability. It does not require advanced clinical judgment unless there are additional complications. Therefore, it does not indicate the need for transfer to a registered nurse.

C. Development of a postoperative fever requires reassessment by a registered nurse because it may indicate infection, atelectasis, or other complications. In a postoperative client, fever is an abnormal finding that requires clinical judgment, evaluation of trends, and possible intervention such as cultures or imaging. This level of assessment exceeds the scope of routine care assignment and warrants RN management.

D. Routine wound care is a predictable and standardized intervention that can often be delegated depending on the complexity of the wound and client condition. It does not inherently require RN-level assessment unless complications such as infection or dehiscence are present. Therefore, it is not a priority reason for care transfer.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Placenta previa is a pregnancy complication in which the placenta implants low in the uterus and partially or completely covers the cervical os. This abnormal positioning can lead to painless vaginal bleeding, especially in the second or third trimester as the cervix begins to efface and dilate. The condition poses a risk for maternal hemorrhage and fetal compromise due to disruption of placental attachment. Clinical management focuses on bleeding assessment, fetal monitoring, and preventing further cervical irritation.

Rationale:
A. Bright red vaginal bleeding is the hallmark finding of Placenta previa. The bleeding is typically painless and results from placental separation as the lower uterine segment stretches. The bright red color indicates fresh arterial bleeding, which is a key distinguishing feature from other obstetric emergencies.

B. A rigid abdomen is more commonly associated with placental abruption rather than placenta previa. In abruption, the placenta detaches prematurely, causing uterine tenderness and a board-like abdomen. Placenta previa typically presents without abdominal pain or uterine rigidity.

C. Increased fetal movement is not a typical finding in placenta previa and does not indicate pathology specific to this condition. Fetal movement patterns may vary but are not diagnostic or expected as a clinical sign of placenta previa. In severe cases of bleeding, fetal activity may actually decrease due to hypoxia.

D. Persistent uterine contractions are not characteristic of placenta previa. The uterus is usually soft and non-tender, and contractions are not a defining feature. If contractions occur, they may suggest labor or another obstetric complication rather than placenta previa.

A. "I'll give my child the iron through a straw." B. "I'll give my child the iron with milk." C. "I'll notify the provider if my child becomes nauseated." D. "I'll notify the provider if my child's stools are tarry."

Correct Answer is A

Explanation

Administration of liquid iron supplements such as Ferrous sulfate in children requires specific teaching to improve absorption and reduce adverse effects. Iron is commonly prescribed for iron deficiency anemia and is best absorbed in an acidic environment, but it can cause staining of teeth and gastrointestinal irritation. Proper administration techniques help improve adherence while minimizing side effects and cosmetic concerns.

Rationale:
A. Giving liquid iron through a straw is appropriate because it helps minimize contact with the teeth and reduces the risk of permanent tooth staining. Ferrous sulfate can discolor enamel, so using a straw and brushing teeth afterward are recommended strategies. This demonstrates correct understanding of safe administration techniques.

B. Giving iron with milk is incorrect because calcium in milk interferes with iron absorption in the gastrointestinal tract. Dairy products bind to iron and reduce its bioavailability, making treatment less effective. Iron should be given with water or vitamin C-rich fluids instead.

C. Mild nausea is a common side effect of iron supplementation and does not require notifying the provider. Gastrointestinal discomfort can often be managed by giving the medication with food (if tolerated) or adjusting timing. Only severe or persistent symptoms would warrant provider notification.

D. Tarry stools are an expected and harmless side effect of oral iron therapy due to unabsorbed iron in the gastrointestinal tract. This change in stool color does not indicate bleeding when the client is taking iron supplements. Parents should be reassured that this is a normal finding.

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 giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with the guardian of a child who has a new prescription for liquid ferrous sulfate. Which of the following statements by the guardian indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the Interprofessional team?

A nurse is reinforcing dietary teaching with a client who is at 12 weeks of gestation. Which of the following statements should the nurse make?

A nurse is preparing to transfer a client to surgery when the client states, "I have changed my mind and don't want to go through with this surgery." Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has GERD. Which of the following instructions should the nurse include?

A nurse is assisting in the care of a client who has tuberculosis. Which of the following personal protective equipment should the nurse wear during routine care for this client?

A nurse is reinforcing teaching with a client about a low-sodium diet. Which of the following foods should the nurse recommend?

A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to Initiate which of the following isolation procedures when caring for this client?

A nurse is assisting with the plan of care for a client who has burns to their lower extremities. Which of the following actions should the nurse Include in the plan?