The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?

A client admitted with a bowel obstruction and is ambulating in the hallway demonstrating a steady gait.

A client admitted with renal colic who had just received morphine 4 mg IV as prescribed.

A client admitted with an infected wound on their right foot, a white blood cell count of 14,000/mm³, and a temperature of 37.7°C.

A client admitted with a tibia fracture scheduled to begin physical therapy with their first crutch walking session.

Answer and Explanation

The Correct Answer is B

Choice A reason: This client, although admitted with a bowel obstruction, is currently demonstrating a steady gait while ambulating, suggesting that they are stable at the moment.

Choice B reason: This client is the priority because they have just received morphine, which requires close monitoring for potential adverse effects, such as respiratory depression. Morphine is a potent opioid, and its administration necessitates vigilant observation to ensure the client's safety.

Choice C reason: While the client with an infected wound and an elevated white blood cell count and temperature requires attention for infection management, the immediate risk of adverse effects from morphine administration takes precedence.

Choice D reason: This client, scheduled to begin physical therapy, is stable enough to participate in planned rehabilitation activities, making them a lower priority compared to the client who has just received a potent opioid.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: The person granted power of attorney for healthcare would be responsible for signing the informed consent only if the client is unable to make decisions for themselves due to incompetence or incapacity. Since the client in this scenario is competent and neurologically intact, the power of attorney is not applicable.

Choice B reason: The client's emergency contact is not authorized to sign informed consent unless they hold legal power of attorney or the client is incapacitated and unable to make decisions. The emergency contact's primary role is to be contacted in emergency situations, not to make medical decisions on behalf of the client.

Choice C reason: The legal next of kin would only be responsible for signing the informed consent if the client is not capable of doing so themselves. In this case, the client is competent and neurologically intact, so the next of kin's consent is not needed.

Choice D reason: The client is responsible for signing the informed consent because they are competent and capable of making their own medical decisions. Informed consent must be obtained from the client directly when they have the capacity to understand and agree to the proposed treatment or procedure.

A. Assign the tasks that were not completed to the next nursing shift. B. Allow each staff member to judge if the task needs to be completed. C. Perform follow-up with each staff member regarding the performance and outcome of each task. D. Document that the task was completed.

Correct Answer is C

Explanation

Choice A reason: Assigning tasks that were not completed to the next nursing shift is a part of shift change protocols but is not the primary responsibility after delegating tasks. Follow-up is crucial to ensure that all tasks are completed correctly and on time.

Choice B reason: Allowing each staff member to judge if the task needs to be completed undermines the importance of the tasks and could lead to inconsistencies in patient care. It is essential to follow up and ensure that the tasks are completed as delegated.

Choice C reason: Following up with each staff member regarding the performance and outcome of each task is critical. This ensures that the tasks are completed correctly, provides an opportunity to address any issues, and reinforces accountability in the team.

Choice D reason: Documenting that the task was completed is important, but it should occur after the nurse has confirmed that the task was performed correctly. Follow-up is essential to verify the accuracy and completeness of the delegated tasks before documentation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an adult client who is scheduled for surgery. The client is competent and neurologically intact. Who would be responsible for signing the informed consent?

Correct Answer is D

Explanation

The nurse working on the medical-surgical unit has delegated several patient care tasks to the unlicensed assistive personnel. What is the nurse's primary responsibility after the delegation of tasks?

Correct Answer is C

Explanation

The charge nurse is planning the staff assignment for the day. Which factors should the nurse consider when planning the assignment? (Select all that apply)

The nurse educator is instructing newly hired nurses about client rights and the legal obligations of hospital staff. Which of the following would be an example to use when describing an assault in a clinical situation?

The nurse is reviewing the laboratory results for a client who is scheduled for knee arthroplasty later in the day. Which laboratory value is most important to report to the health care provider before the surgery?

A nurse discovers that a client was administered an antihypertensive medication in error. What would be the priority action for the nurse to do first?

The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?

A hospital is preparing to receive a large number of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge?