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The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

An 82-year-old client with Alzheimer's disease and a newly fractured femur who has an indwelling urinary catheter and soft wrist restraints applied.

A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race.

A 34-year-old admitted today after an emergency appendectomy who has a PIV and indwelling urinary catheter.

A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline lock PIV.

Answer and Explanation

The Correct Answer is A

A. The combination of cognitive impairment, physical injury, and restraints poses a high risk for complications such as infection, skin breakdown, and falls. Close monitoring and nursing interventions are critical to ensure safety, comfort, and appropriate care in this patient.

B. While this client may need some care for the electrolyte imbalance and nausea, this situation is more stable compared to the elderly client with Alzheimer's. The RN's role here would focus on managing the electrolyte disturbance and providing symptom relief.

C. Although this client is postoperative and may need some care, the RN's focus would primarily be on pain management and monitoring for infection or complications. However, the client’s condition is relatively stable compared to the elderly client with multiple risks.

D. This client is also stable and may require some ongoing monitoring for respiratory issues. However, the level of care needed is less intensive compared to a client with cognitive issues, restraints, and a recent fracture.

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Correct Answer is A

Explanation

A. Procure platelet products from the blood bank: UAPs may be delegated non-invasive tasks such as transporting lab specimens or retrieving blood products. This task does not require nursing judgment and is appropriate for delegation under routine supervision.

B. Titrate oxygen to the prescribed parameters: Titrating oxygen requires assessment and clinical judgment, as adjustments depend on vital signs and client condition. This is within the RN or LPN scope, not the UAP’s, due to the potential for rapid status changes.

C. Insert a urinary catheter for an uncomplicated client: Insertion of catheters is an invasive procedure that requires sterile technique and knowledge of anatomy. This task must be performed by a licensed nurse, not a UAP, even in uncomplicated cases.

D. Monitor an IV infusion rate on an established schedule: Although observation is within the UAP role, monitoring IV infusions involves understanding flow rates, recognizing signs of infiltration or complications, and making clinical decisions, all of which exceed UAP scope.

A. Instruct the client to cough as the suction tip is removed. B. Instil 3 mL of 0.9% sodium chloride before suctioning. C. Wear protective goggles while performing the procedure. D. Apply a water soluble lubricant to the catheter.

Correct Answer is C

Explanation

A. Instruct the client to cough as the suction tip is removed: Coughing can help clear secretions, but this action is not the primary safety concern during suctioning. The priority is minimizing the risk of injury, infection, and contamination during the procedure

B. Instil 3 mL of 0.9% sodium chloride before suctioning: Instilling saline before suctioning is generally not recommended as it can lead to complications, such as increasing mucus production, which can make suctioning more difficult.

C. Wear protective goggles while performing the procedure: Suctioning a tracheostomy can involve secretions that may potentially splash, so it’s important to wear protective goggles, as well as other appropriate personal protective equipment, to ensure safety and prevent contamination.

D. Apply a water-soluble lubricant to the catheter: Applying lubricant to the catheter is not recommended. The suction catheter should be kept sterile and dry to avoid introducing any contaminants into the trachea or the airway.

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The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is C

Explanation

The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

A client reports passing 2 to 3 small, hard stools per week since being placed on a low-residue diet three months ago. Which type of laxative should the nurse expect the healthcare provider to recommend first?

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?