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 A

Explanation

Choice A reason: Administering an intramuscular injection is within the LPN’s scope of practice, ensuring safe delegation. This aligns with nursing delegation guidelines, making it the correct example of appropriate task assignment for the nurse to delegate to the LPN on a busy unit.

Choice B reason: Assessing a wound for infection requires RN judgment, exceeding the LPN’s scope. Administering an injection is appropriate, making this incorrect, as it’s an improper delegation compared to the nurse’s choice of a task within the LPN’s role.

Choice C reason: MAs cannot discuss test results, as this requires clinical judgment beyond their scope. LPN injection administration is correct, making this incorrect, as it’s an inappropriate task for the MA compared to the nurse’s proper delegation choice.

Choice D reason: Inserting a nasogastric tube is an RN task, not within the MA’s scope. LPN injection administration is appropriate, making this incorrect, as it’s unsafe delegation compared to the nurse’s selection of a task suitable for the LPN.

A. Administer furosemide (Lasix) 40 mg IV. B. Decrease the rate of the IV fluids and notify the health care provider. C. Document the CVP reading in the chart. D. Check the client’s urine specific gravity.

Correct Answer is B

Explanation

Choice A reason: Administering furosemide without a provider’s order is outside nursing scope and risks harm. Decreasing IV fluids addresses elevated CVP, making this incorrect, as it bypasses protocol compared to the nurse’s priority of adjusting fluids and consulting the provider.

Choice B reason: A CVP of 16 cm H2O suggests fluid overload; decreasing IV fluids and notifying the provider prevents worsening heart failure. This aligns with hemodynamic monitoring protocols, making it the correct action for the nurse to take to address the client’s elevated CVP.

Choice C reason: Documenting the CVP is necessary but doesn’t address the urgent fluid overload indicated by 16 cm H2O. Decreasing fluids is proactive, making this incorrect, as it delays intervention compared to the nurse’s priority of managing the client’s high CVP.

Choice D reason: Checking urine specific gravity assesses hydration but is less urgent than addressing elevated CVP with fluid adjustment. Notifying the provider takes precedence, making this incorrect, as it’s secondary to the nurse’s action to manage fluid overload immediately.

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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

You are working on a busy unit and need to delegate tasks to the LPN and M

Correct Answer is A

Explanation

The nurse cares for a client with 0.9% sodium chloride infusing at 125 mL/h. 2 hours after the infusion was started, the client’s central venous pressure (CVP) reading is 16 cm H2O. It is MOST important for the nurse to take which action?

Correct Answer is B

Explanation

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