During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first?

A bucket of water was spilled in the hallway.

One staff member has not reported to work.

A client's wife has asked to speak with the charge nurse.

The census report has not been completed.

Answer and Explanation

The Correct Answer is A

Rationale:

A. A bucket of water was spilled in the hallway: This represents an immediate safety hazard for staff, clients, and visitors. Wet floors can lead to serious falls and injuries, so it must be addressed first to prevent harm and liability.

B. One staff member has not reported to work: While staffing shortages impact workload and coverage, they do not present an immediate physical danger. This issue can be addressed after eliminating urgent environmental risks.

C. A client's wife has asked to speak with the charge nurse: Family concerns are important and should be acknowledged, but they do not carry the urgency of an environmental safety threat. The nurse can follow up after resolving more pressing issues.

D. The census report has not been completed: Completing paperwork is essential for administrative tracking and planning, but it does not directly impact client safety. It should be prioritized after more urgent clinical and safety concerns are handled.

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Correct Answer is D

Explanation

Rationale:

A. Low intermittent suction prescribed for the nasogastric tube is turned off: While nasogastric suction helps prevent gastric distention and vomiting, turning it off temporarily is not immediately dangerous. This should be addressed but does not pose an urgent risk if the client is stable.

B. The urinary catheter drainage bag is almost completely full of amber urine: Although the bag should be emptied to prevent backflow or tension on the catheter, amber urine is expected and not concerning. This is a routine task and does not indicate an urgent issue.

C. Oxygen is being administered via nasal cannula at 4 L/min without humidification:
Oxygen at this rate may cause nasal dryness if humidification is not used, but this does not create an immediate threat to client safety. It should be corrected, but it’s not the most critical concern.

D. A Hemovac drain is partially full of serous drainage and is not compressed: The Hemovac must remain compressed to provide negative pressure for continuous drainage. If not compressed, fluid can accumulate at the surgical site, increasing infection and hematoma risk. This requires prompt correction to prevent postoperative complications.

A. Instruct the client to shower and wash her hair thoroughly. B. Clean all surfaces touched by the client with vinegar and water. C. Place the client in a room with lead doors to contain airborne anthrax. D. Bag the clothes the client is wearing in plastic bags. E. Place the client on airborne precautions.

Correct Answer is ["A","D","E"]

Explanation

Rationale:

A. Instruct the client to shower and wash her hair thoroughly: Decontamination by showering is essential to remove any anthrax spores from the skin and hair. Thorough washing reduces the risk of further spread and protects healthcare personnel and other patients.

B. Clean all surfaces touched by the client with vinegar and water: Vinegar and water are not effective against anthrax spores. Proper decontamination requires specific agents, such as a 0.5% hypochlorite (bleach) solution, under the guidance of hazardous materials protocols.

C. Place the client in a room with lead doors to contain airborne anthrax: Lead doors are used for radiation containment, not for biological threats like anthrax. Anthrax is not typically airborne unless aerosolized, so this intervention is unnecessary and ineffective.

D. Bag the clothes the client is wearing in plastic bags: Contaminated clothing can carry anthrax spores. Placing clothes in sealed plastic bags is a critical step in preventing environmental contamination and ensuring safe disposal.

E. Place the client on airborne precautions: While anthrax is not usually spread from person to person, airborne precautions are used if aerosol exposure is suspected, as in bioterrorism events. This helps contain spores until full decontamination is completed.

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During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Correct Answer is D

Explanation

Correct Answer is ["A","D","E"]

Explanation

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