After obtaining handoff communication from the previous shift's nurse, the nurse knows that which client is the PRIORITY?
A 75-year-old client who can perform active ROM exercises independently and will be discharged today.
A 24-year-old client who is grieving after receiving a cancer diagnosis.
A 65-year-old client who has been admitted from a long-term care facility and has several wounds with slough.
A 55-year-old client who is newly admitted and is refusing to be turned every 2 hours.
The Correct Answer is D
A. A 75-year-old client who can perform active ROM exercises independently and will be discharged today: Independence with ROM and imminent discharge indicate relative stability and lower immediate risk compared with other options.
B. A 24-year-old client who is grieving after receiving a cancer diagnosis: Emotional support and assessment are important, but grief alone is not immediately life- or safety-threatening compared with clients at higher risk for physical deterioration.
C. A 65-year-old client who has been admitted from a long-term care facility and has several wounds with slough: Multiple sloughing wounds increase risk for infection and require prompt wound assessment and treatment; this client has significant care needs.
D. A 55-year-old client who is newly admitted and is refusing to be turned every 2 hours: This refusal places the client at immediate risk for pressure injury and other immobility complications; because the client is newly admitted and actively refusing a basic safety measure, assessing the reason for refusal and initiating interventions to prevent harm make this the priority for immediate nursing action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tuberculin: Tuberculin syringes are intended for small intradermal or small subcutaneous doses; their narrow barrel can generate higher pressure and they may not have a locking connection suitable for IV push.
B. Leur-lock: A Luer-lock syringe provides a threaded, secure connection to IV tubing or needleless connectors, reducing the risk of accidental disconnection or leakage during an IV push -this makes it the safest choice for IV administration.
C. Insulin: Insulin syringes are unit-calibrated specifically for insulin dosing and are not designed for IV administration; using them for IV pushes risks dosing errors and inappropriate equipment use.
D. Non Leur-lock: Slip-tip (non-Luer-lock) syringes can become detached during use, increasing the chance of spills or needlestick/contamination events, so they are less safe for IV pushes.
Correct Answer is A
Explanation
A. Changing the bedding and client's gown: Routine hygiene and linen changes are typical tasks that can be delegated to assistive personnel (AP) with appropriate guidance.
B. Asking the family about organ and tissue donation: Discussions about organ/tissue donation require specific clinical, legal, and consent knowledge and are responsibilities of the licensed nurse or physician; this conversation should not be delegated to AP.
C. Helping to wash and prepare the body: Assisting with post-death care and preparing the body for family viewing can be delegated to AP with clear instruction and supervision.
D. Performing oral care on a client's dentures: Providing basic oral care, including cleaning dentures, is within the scope of AP duties when delegated.
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