A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?
A client who is 4 days postpartum and has mastitis
A client who had a bilateral tubal ligation 12 hr previously
A client admitted 1 hr ago for an ectopic pregnancy
A client who is a 1 day postpartum after a late term miscarriage
The Correct Answer is C
Rationale:
A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.
B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.
C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.
D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
False Imprisonment: This refers to the unlawful restraint of an individual's freedom of movement. By applying wrist restraints without a clear and immediate order from a provider or without proper justification, the nurse could be restricting the client's freedom of movement inappropriately.
Applying wrist restraints to the client: This action is a key factor in the potential for false imprisonment. Restraints should be used only when necessary and with proper authorization and documentation, particularly in non-emergency situations.
Correct Answer is B
Explanation
Rationale:
A. Call the provider for a stat DNR order is not appropriate as the client is already in a critical state requiring immediate action.
B. Call the emergency response team is necessary as the client is pulseless, and resuscitation should be initiated according to standard procedures until a DNR order is confirmed.
C. Seek immediate help from the risk manager is not appropriate at this moment; the immediate concern is the client's emergency situation.
D. Respect the family's wishes and do nothing is not appropriate as immediate life-saving measures should be taken until a formal DNR order is in place.
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