A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?
"The client who had abdominal surgery 3 days ago is reporting feeling constipated.”
"The client who had the hip replacement reports pain as 4 on a scale of 0 to 10.”
"The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.”
"The client who is scheduled for discharge today states they are ready to sign their paperwork.”
The Correct Answer is C
Choice A rationale:
The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.
Choice B rationale:
The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.
Choice C rationale:
The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.
Choice D rationale:
The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "I delegate tasks to personnel based on their job descriptions."
Choice A rationale:
The response "I delegate tasks to personnel based on their job descriptions" is appropriate in this situation. Charge nurses are responsible for delegating tasks based on the scope of practice and job descriptions of the staff members. This response emphasizes the importance of adhering to established roles and responsibilities within the healthcare team.
Choice B rationale:
The statement "Everyone working here has to care for clients who are incontinent" may be true, but it does not address the specific concern raised by the assistive personnel (AP). It's important to provide a more focused response that addresses the AP's feelings and concerns.
Choice C rationale:
While discussing workflow organization to reduce the number of incontinent clients (Choice C) might be a potential solution, it doesn't directly address the AP's statement about fairness. The charge nurse's response should prioritize explaining the delegation process and addressing the AP's concerns about fairness.
Choice D rationale:
The response "Why do you not want to care for clients who are incontinent?" could be perceived as confrontational and defensive. It's essential to maintain a respectful and supportive tone when addressing staff concerns. This response does not effectively address the situation or provide a solution.
Correct Answer is B
Explanation
The correct answer is choice B: Perform a chart review to gather data about the clients who developed infections.
Choice A rationale: Conducting an in-service on proper catheter insertion and maintenance may be helpful in addressing the issue but should not be the first step.
Choice B rationale: Performing a chart review to gather data about the clients who developed infections is an essential first step. This allows the nurse manager to analyze potential trends or common factors contributing to the infections, which can help identify specific areas for improvement or intervention (NurseLabs, n.d.).
Choice C rationale: Observing each staff nurse perform a urinary catheter insertion could help identify improper techniques that contribute to the infections. However, this is time-consuming and should be done after a chart review has been conducted.
Choice D rationale: Requiring completion of a self-paced instruction program might improve staff knowledge, but it should not be the first action taken by the nurse manager.
In conclusion, the nurse manager should first perform a chart review to gather data about the clients who developed urinary tract infections. This will help identify possible factors contributing to the infections and guide the nurse manager in developing targeted interventions to address the issue.
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