After receiving the change-of-shift report, which client does the nurse assess first?

A 45-year-old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

A 57-year-old receiving IV diuretics whose blood pressure is 88/52 mm Hg.

A 67-year-old with nausea and vomiting who reports abdominal cramps.

A 77-year-old with normal saline infusing at 150 mL/hr with an average hourly urine output.

Answer and Explanation

The Correct Answer is B

Choice A reason: Dry mucosa and thirst suggest dehydration, but hypotension (88/52) is more life-threatening. Low blood pressure requires immediate assessment, making this incorrect, as it’s less urgent than the nurse’s priority to address the client with critical hemodynamic instability.

Choice B reason: A blood pressure of 88/52 mm Hg in a client on IV diuretics indicates severe hypotension, a life-threatening condition requiring immediate assessment. This aligns with prioritization in acute care, making it the correct client for the nurse to assess first post-shift report.

Choice C reason: Nausea, vomiting, and cramps are concerning but less urgent than hypotension (88/52), which risks organ perfusion. Low blood pressure is critical, making this incorrect, as it’s secondary to the nurse’s priority of assessing the client with unstable vitals.

Choice D reason: Normal saline at 150 mL/hr with adequate urine output is stable. Hypotension (88/52) is more critical, making this incorrect, as it’s a lower priority compared to the nurse’s need to assess the client with life-threatening low blood pressure first.

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Correct Answer is D

Explanation

Choice A reason: Nonmaleficence ensures no harm but is secondary to veracity, which provides truthful information for consent. Truthfulness is critical, making this incorrect, as it’s not the primary ethical principle the nurse prioritizes when soliciting informed consent from a patient.

Choice B reason: Fidelity involves keeping promises but doesn’t directly ensure the patient receives accurate information for consent. Veracity is key, making this incorrect, as it’s less relevant than the nurse’s focus on truthfulness during the informed consent process.

Choice C reason: Beneficence promotes well-being but is less critical than veracity, which ensures informed decision-making. Truthful disclosure is primary, making this incorrect, as it’s secondary to the nurse’s ethical priority when obtaining informed consent from the patient.

Choice D reason: Veracity, or truthfulness, is the most important principle, ensuring the patient receives accurate information for informed consent. This aligns with ethical standards, making it the correct principle the nurse prioritizes to support autonomous decision-making during the consent process.

A. Clamp the T-tube. B. Irrigate the T-tube. C. Notify the surgeon. D. Document the findings.

Correct Answer is C

Explanation

Choice A reason: Clamping the T-tube risks bile backup and infection, especially with 750 mL drainage. Notifying the surgeon addresses potential complications, making this incorrect, as it’s unsafe compared to the nurse’s priority of reporting excessive T-tube output.

Choice B reason: Irrigating the T-tube without medical orders risks dislodging it or causing infection. Notifying the surgeon is appropriate for 750 mL drainage, making this incorrect, as it’s risky compared to the nurse’s action to seek medical evaluation.

Choice C reason: Notifying the surgeon is most appropriate, as 750 mL of T-tube drainage may indicate a complication like bile leak or obstruction. This aligns with post-surgical care protocols, making it the correct intervention for the nurse to address excessive drainage.

Choice D reason: Documenting is necessary but doesn’t address the potential complication of 750 mL drainage. Notifying the surgeon is urgent, making this incorrect, as it delays the nurse’s priority of reporting a significant post-surgical T-tube output to the surgeon.

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After receiving the change-of-shift report, which client does the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which ethical principle is most important when soliciting informed consent from a patient?

Correct Answer is D

Explanation

The nurse notes that a client’s T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Correct Answer is C

Explanation

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

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The nurse is taking care of a 60-year-old client who is scheduled for open reduction internal fixation of the left femur. Which ethical principle is most important when soliciting informed consent from the patient?

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