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 B

Explanation

Choice A reason: Ensuring transfer of the client's electronic chart code is a necessary action, but it is not the most important. The nurse should make sure that the client's records are updated and accessible to the palliative care team, but this can be done after the client is settled in the new room.

Choice B reason: Giving a detailed report to the accepting nurse is the most important action, as it ensures continuity and quality of care for the client. The nurse should provide information about the client's diagnosis, prognosis, preferences, goals, medications, interventions, and family situation.

Choice C reason: Giving client written information about end-of-life care is a helpful action, but it is not the most important. The nurse should provide the client with educational materials and resources about palliative care, hospice care, advance directives, and bereavement support, but this can be done later or by the palliative care team.

Choice D reason: Taking the family to the client's new room is a supportive action, but it is not the most important. The nurse should assist the family with the transition and offer emotional support, but this can be done after the report is given to the accepting nurse.

A. Discuss with the family about placing the client in a skilled care facility. B. Determine if the client is manifesting other neurologic changes. C. Apply a restraining device to prevent the client from self injury. D. Request family members report when the client is left alone.

Correct Answer is B

Explanation

Choice A reason: Discussing with the family about placing the client in a skilled care facility is not the most important intervention for the nurse to implement. The client may have a temporary or reversible condition that caused the agitation and confusion. The nurse should not assume that the client needs long-term care without further assessment and evaluation.

Choice B reason: Determining if the client is manifesting other neurologic changes is the most important intervention for the nurse to implement. The client's behavior may indicate a serious complication such as delirium, infection, hypoxia, electrolyte imbalance, or medication reaction. The nurse should assess the client's mental status, vital signs, oxygen saturation, blood glucose, and laboratory results to identify the cause and severity of the problem.

Choice C reason: Applying a restraining device to prevent the client from self injury is not the most important intervention for the nurse to implement. The use of restraints should be avoided as much as possible and only used as a last resort when other alternatives have failed. The nurse should first assess the situation and intervene to address the underlying issue and calm the client.

Choice D reason: Requesting family members report when the client is left alone is not the most important intervention for the nurse to implement. The client may not have any family members present or involved in the care. The nurse should not rely on the family to monitor the client's safety and well-being. The nurse should ensure that the client is frequently checked and observed by the staff.

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Naxlex Comprehensive Predictor Exams

An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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