A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

"The client works in the hospital radiology department."

"The client discussed having prior thoughts of suicide."

"The client's blood pressure and pulse have been fluctuating throughout the day."

"The client's family members have been present most of the day."

Answer and Explanation

The Correct Answer is C

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

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Correct Answer is A

Explanation

Rationale:

A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is the most critical task to ensure that the infant is safe and that the postoperative care is being managed correctly.

B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma is less urgent compared to tasks directly related to patient safety and postoperative care.

C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking the safety equipment for a postoperative infant.

D. Engage a toddler in play is beneficial but less urgent than tasks related to immediate postoperative care and safety.

A. "HICS is focused on having multidisciplinary responders available." B. "HICS ensures that necessary antibiotics and antidotes are available." C. "HICS provides additional responders when needs exceed the ability of local or state agencies." D. "HICS identifies facility responsibilities and channels of reporting."

Correct Answer is D

Explanation

Rationale:

A. HICS focuses on organizing and managing internal facility operations rather than mobilizing external multidisciplinary responders.

B. HICS does not directly ensure the availability of specific medical supplies; this is usually managed through other systems or protocols.

C. HICS is primarily concerned with internal facility management, not providing additional responders from outside agencies.

D. HICS helps to define roles, responsibilities, and reporting channels within the facility during a disaster, ensuring effective internal management.

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A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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