A nurse is starting a shift in an acute care setting and receives the following client reports. Which client should the nurse prioritize to assess first?
A client in heart failure with 2+ edema in the lower extremities
A client with pneumonia and a saturation of 92%
A post-op client with no bowel sounds in the last 12 hours
A client in renal failure with elevated serum potassium levels needing dialysis
The Correct Answer is D
Rationale:
A. A client in heart failure with 2+ edema in the lower extremities is incorrect as this indicates mild fluid retention, which is concerning but not immediately life-threatening. The client should be monitored, but this is not the highest priority.
B. A client with pneumonia and a saturation of 92% is incorrect because while hypoxia requires attention, an SpO₂ of 92% is mildly decreased and can typically be managed with supplemental oxygen and monitoring. It is important but less urgent than severe electrolyte imbalance.
C. A post-op client with no bowel sounds in the last 12 hours is incorrect because absent bowel sounds may indicate ileus, which is concerning but generally not immediately life-threatening. It requires assessment and monitoring but is lower priority compared to severe electrolyte disturbances.
D. A client in renal failure with elevated serum potassium levels needing dialysis is correct because hyperkalemia is potentially life-threatening and can cause fatal cardiac arrhythmias. Clients with elevated potassium levels require immediate assessment and intervention to prevent cardiac arrest, making this the highest priority for the nurse at the start of the shift.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. It is focused solely on resolving conflicts within healthcare teams is incorrect because while conflict resolution can be part of collaboration, the process encompasses much more, including shared planning, decision-making, and coordinated care, not just addressing disputes.
B. It is limited to communication between nurses and patients is incorrect because collaboration extends beyond nurse-patient interactions. It involves interprofessional teamwork, integrating the expertise of physicians, therapists, social workers, and other healthcare providers to optimize patient outcomes.
C. It requires nurses to work jointly with other healthcare professionals to provide comprehensive care to clients is correct because nursing collaboration involves active participation in interdisciplinary teams, sharing knowledge, coordinating interventions, and jointly planning care to meet complex patient needs. This approach enhances safety, efficiency, and quality of care.
D. It involves solitary decision-making to ensure patient autonomy is incorrect because solitary decision-making does not reflect collaboration. While respecting patient autonomy is essential, collaboration emphasizes joint planning and shared responsibility among healthcare professionals.
Correct Answer is B
Explanation
Rationale:
A. Her formal nursing education which prepared her for organizational leadership is incorrect because Clara Barton did not have formal nursing education. She was largely self-taught and gained experience through hands-on care and humanitarian work.
B. Her experiences during the U.S. Civil War witnessing the desperate needs of soldiers is correct because Barton’s direct exposure to the suffering of wounded and dying soldiers motivated her to provide organized relief efforts. These experiences inspired her to establish the American Red Cross to deliver emergency assistance, disaster relief, and humanitarian aid in both war and peacetime, formalizing her commitment to organized nursing and humanitarian service.
C. Her travels to Europe to study medicine and advanced nursing techniques is incorrect because, although Barton was influenced by international humanitarian practices (including the work of the International Red Cross), her foundational motivation came from her Civil War experiences rather than formal European medical training.
D. Her advocacy for mental health reform and indigenous rights inspired her efforts is incorrect because, although social reform was a component of Barton’s broader life work, it was her wartime nursing experiences and exposure to suffering that specifically led her to create the American Red Cross.
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