A nurse is receiving a change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg.

A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10.

A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 ml/hr

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.

Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.

Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.

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Correct Answer is D

Explanation

The nurse should approach the man and ask why he is making copies of the client's medical records. This action allows the nurse to directly address the situation and gather more information before taking further steps.
Option A, may not be the best initial action because it does not directly address the situation.
Option B may be premature without first gathering more information.
Option C, may also not be the best initial action because it does not directly address the situation.

A. Correct the mistake independently. B. Speak with the other nurse privately. C. Volunteer to perform the procedure next time. D. Submit an incident report.

Correct Answer is B

Explanation

The first action the nurse should take is to speak with the other nurse privately. This allows the nurse to address the mistake in a respectful and professional manner and provide guidance on how to perform the procedure correctly in the future.
Option A is incorrect because correcting the mistake independently does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option C is incorrect because volunteering to perform the procedure next time does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option D is incorrect because submitting an incident report may be necessary, but it should not be the first action taken.

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A nurse is receiving a change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse observes another nurse performing a procedure in the incorrect sequence. The procedure does not harm the client. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is observing an assistive personnel (AP). For which of the following actions by the AP should the nurse intervene?

A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Which situation can lead to a tort against a nurse? SELECT ALL THAT APPLY:

What is a nurse's best protection against negligence or malpractice?

A nurse is assigning tasks for the upcoming shift. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This is an example of which ethical principle?

A nurse on a pediatric unit is working with an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?

When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This adherence to an essential ethical principle is: