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 C

Explanation

Choice A reason: A child who has had a cold for two days and now is coughing up green sputum is not the most urgent client to assess. The child may have a bacterial infection that requires antibiotics, but the condition is not life-threatening or unstable. The child can be classified as urgent and seen within one hour.

Choice B reason: A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak is not the most urgent client to assess. The adolescent may have dehydration, electrolyte imbalance, or gastroenteritis that requires fluid replacement and antiemetics, but the condition is not life-threatening or unstable. The adolescent can be classified as urgent and seen within one hour.

Choice C reason: A female client with severe right lower abdominal pain who is febrile and vomiting is the most urgent client to assess. The client may have appendicitis, ovarian torsion, ectopic pregnancy, or another serious condition that requires immediate diagnosis and treatment. The client is at risk of perforation, infection, shock, or hemorrhage and needs to be seen as soon as possible. The client can be classified as emergent and seen within 15 minutes.

Choice D reason: An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating is not the most urgent client to assess. The client may have intermittent claudication, ischemia, or ulceration that requires analgesics, antiplatelets, or vascular surgery, but the condition is not life-threatening or unstable. The client can be classified as semi-urgent and seen within two hours.

A. Assign the UAP to provide care for another client and assume full care of the client. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Correct Answer is C

Explanation

Choice A reason: Assigning the UAP to provide care for another client and assuming full care of the client is not the best action for the nurse to take. This may disrupt the continuity of care and the rapport between the UAP and the client. It may also be unnecessary and inefficient for the nurse to take over the care of the client.

Choice B reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not the best action for the nurse to take. This may be incorrect and inappropriate for the prevention of pertussis transmission. A fitted respirator mask is used for airborne precautions, while pertussis is spread by droplet contact.

Choice C reason: Reviewing the need for the UAP to wear a face mask while in close contact with the client is the best action for the nurse to take. This can educate the UAP about the proper infection control measures for pertussis, which include droplet precautions. A face mask can prevent the UAP from inhaling or spreading the droplets that contain the bacteria.

Choice D reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not the best action for the nurse to take. This may be irrelevant and redundant for the situation. The UAP should already know to report any changes in the client's condition to the nurse, regardless of the diagnosis or the intervention.

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Naxlex Comprehensive Predictor Exams

When triaging emergency room clients, which client should the nurse assess first?

Correct Answer is C

Explanation

A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UAP) donning a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?

Correct Answer is C

Explanation

The charge nurse is making assignments for a 15-bed skilled nursing unit with the staff of one nurse, two practical nurses (PN), and two unlicensed assistive personnel (UAP). Which client should be assigned to the PN?

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?

In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat and sleeps most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?

The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?