The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?

A client with chest tubes secondary to a stab wound to the chest.

A client in end-stage liver failure who is experiencing esophageal bleeding.

A client with multisystem failure secondary to a motor vehicle collision.

A client with Adult Respiratory Distress Syndrome who is on a ventilator.

Answer and Explanation

The Correct Answer is A

Choice A reason: A client with chest tubes secondary to a stab wound to the chest is the best client to assign to the new graduate nurse. The client has a stable and predictable condition that requires routine care and monitoring. The client does not have any complex or unstable problems that may require advanced skills or interventions. The new graduate nurse has the knowledge and skills to manage the client's chest tubes and wound care.

Choice B reason: A client in end-stage liver failure who is experiencing esophageal bleeding is not the best client to assign to the new graduate nurse. The client has a critical and unpredictable condition that requires frequent assessment and intervention. The client may have complications such as hepatic encephalopathy, coagulopathy, ascites, or sepsis that may require advanced skills or interventions. The new graduate nurse may not have the experience or confidence to handle the client's situation.

Choice C reason: A client with multisystem failure secondary to a motor vehicle collision is not the best client to assign to the new graduate nurse. The client has a complex and unstable condition that requires intensive care and monitoring. The client may have multiple injuries, organ damage, or infections that may require advanced skills or interventions. The new graduate nurse may not have the competence or judgment to deal with the client's condition.

Choice D reason: A client with Adult Respiratory Distress Syndrome who is on a ventilator is not the best client to assign to the new graduate nurse. The client has a severe and unstable condition that requires mechanical ventilation and hemodynamic support. The client may have complications such as pulmonary edema, hypoxemia, or septic shock that may require advanced skills or interventions. The new graduate nurse may not have the expertise or skill to manage the client's ventilator and hemodynamic status.

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Correct Answer is D

Explanation

Choice A reason: This is not a correct assignment because the PN cannot obtain a report on a client with unstable angina, which is a complex and potentially life-threatening condition that requires the RN's assessment and intervention.

Choice B reason: This is not a correct assignment because the UAP cannot assist with the thoracentesis, which is an invasive and high-risk procedure that requires the RN's or the healthcare provider's skills and knowledge.

Choice C reason: This is not a correct assignment because the RN should not leave the unit to obtain report on a new admission while a thoracentesis is being performed. The RN should be available to monitor the client's vital signs, oxygen saturation, and potential complications during and after the procedure.

Choice D reason: This is a correct assignment because the PN can go to the ED to obtain report and transport the client with unstable angina, which is within the PN's scope of practice. The UAP can prepare the room for the new admission, which is a simple and routine task. The RN can assist with the thoracentesis, which is an advanced and critical skill.

A. A client with acute kidney injury who is somnolent and does not respond to verbal commands. B. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6 F (38.1 C). C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus. D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.

Correct Answer is A

Explanation

Choice A reason: This is the most urgent situation, as the client may have uremic encephalopathy, a serious complication of acute kidney injury that affects the brain function. The nurse should assess the client's neurological status, check the serum electrolytes and blood urea nitrogen (BUN) levels, and notify the provider immediately.

Choice B reason: This is a concerning situation, as the client may have a fever due to an infection or a reaction to the enteral feeding. The nurse should monitor the client's vital signs, check the feeding tube for patency and placement, and obtain a blood culture if ordered.

Choice C reason: This is a significant situation, as the client may have dehydration, electrolyte imbalance, and organ damage due to the heat stroke. The nurse should monitor the client's fluid intake and output, check the serum electrolytes and creatinine levels, and provide cooling measures as needed.

Choice D reason: This is a relevant situation, as the client may have dehydration, electrolyte imbalance, and nutritional deficiency due to the hyperemesis gravidarum. The nurse should monitor the client's fluid intake and output, check the serum electrolytes and glucose levels, and provide antiemetic medication as prescribed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Which client requires the most immediate intervention by the nurse?

Correct Answer is A

Explanation

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