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 B

Explanation

When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This is an example of the ethical principle of nonmalfeasance. Nonmalfeasance refers to the principle of "do no harm" and requires healthcare providers to avoid causing harm to their patients.
Option A refers to wrongdoing or misconduct and is not applicable in this situation.
Option C refers to truthfulness and honesty, but it is not the primary principle being demonstrated in this situation.
Option D refers to fairness and equality, but it is not the primary principle being demonstrated in this situation.

A. Give fresh water to each client who does not have NPO status. B. Obtain a routine urine sample from a client right after admission. C. Transport a client to the radiology department for an x-ray. D. Take an ABG specimen to the laboratory.

Correct Answer is D

Explanation

The nurse should ask the AP to perform the task of taking an ABG (arterial blood gas) specimen to the laboratory first. This is because ABG specimens need to be analyzed promptly to ensure accurate results. Timely analysis of ABG specimens is important for making clinical decisions and providing appropriate care to the client.
Option A is incorrect because giving fresh water to clients who do not have NPO status is not as time-sensitive as taking an ABG specimen to the laboratory.
Option B is incorrect because obtaining a routine urine sample from a client right after admission is not as time-sensitive as taking an ABG specimen to the laboratory.
Option C is incorrect because transporting a client to the radiology department for an x-ray is not as time-sensitive as taking an ABG specimen to the laboratory.

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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?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A nurse is performing care for several clients with the help of an assistive personnel (AP). Which task should the nurse ask the AP to perform first?

Correct Answer is D

Explanation

A nurse tells another nurse that she thinks that he did not provide adequate care for a client who underwent a hip arthroplasty earlier that day. Which of the following responses by the accused nurse demonstrates assertiveness?

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

A nurse enters a client's room and finds the client on the ﬂoor. Which of the following actions should the nurse take first?

A nurse asks an assistive personnel (AP) to take a specimen to the laboratory, and the AP refuses. Which of the following actions should the nurse take?

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?

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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.)

A nurse is reinforcing teaching about delegation to assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?