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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Providing nasopharyngeal suctioning for a client with pneumonia is within the scope of practice for an LPN. This task involves performing a procedure to clear the airway, which is a common responsibility for LPNs.

Choice B reason: Assisting a client who is 24 hours post-operative to use an incentive spirometer is appropriate for an LPN. This task involves helping a client with breathing exercises to prevent post-operative complications, which is a standard part of post-operative care.

Choice C reason: Teaching a new client who has asthma to use a metered-dose inhaler requires educational and assessment skills that typically fall within the scope of practice for a registered nurse (RN). While LPNs can reinforce education, the initial teaching and assessment of a client's understanding should be done by an RN.

Choice D reason: Collecting a clean catch urine from an ambulatory client with a wound is within the scope of practice for an LPN. This task involves obtaining a urine sample, which is a routine procedure that LPNs are trained to perform.

A. Incident reports are the appropriate method of reporting to state, local, and federal agencies. B. Incident reports determine the effectiveness of interventions in relation to outcomes. C. Incident reports help to provide clients with necessary treatment. D. Incident reports help institutions identify risk situations and improve client care.

Correct Answer is D

Explanation

Choice A reason: Incident reports are internal documents used within the hospital to record and analyze adverse events. They are not intended for direct reporting to state, local, and federal agencies, which have their own reporting mechanisms.

Choice B reason: While incident reports may indirectly contribute to assessing the effectiveness of interventions, their primary purpose is not to determine outcomes. Instead, they focus on documenting and analyzing incidents to prevent future occurrences.

Choice C reason: Providing necessary treatment to clients is the immediate response to an incident. However, the purpose of the incident report is broader—it aims to capture the details of the event for analysis and future prevention, not directly to ensure treatment.

Choice D reason: The primary purpose of an incident report is to help the institution identify risk situations and improve client care. By systematically documenting incidents, the hospital can analyze patterns, identify areas for improvement, and implement strategies to enhance safety and quality of care.

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

An experienced charge nurse is providing mentoring to a new charge nurse. The new charge nurse is making the shift assignment for a licensed practical nurse (LPN). Which assignment requires intervention by the experienced nurse?

Correct Answer is C

Explanation

The nurse working on a medical-surgical unit finds a client lying on their bathroom floor. After assessing the client and notifying the provider and nursing supervisor, the nurse completes a hospital incident report. What is the purpose of completing the hospital incident report?

Correct Answer is D

Explanation

The nurse is counseling a new client who identifies as a transgender female and is expressing the desire to start estrogen therapy for their transition. What potential complication will the nurse include in the client teaching?

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?

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?

The nurse is caring for a client on the medical unit when the waste basket catches fire. What is the priority action for the nurse?

The nurse is caring for a client being prepared for a left total knee replacement surgery. The nurse is witnessing the surgeon obtain informed consent before the procedure. Which essential components must be present to obtain informed consent? (Select all that apply)

A newly hired nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the nurse educator best provides information about this aspect of therapeutic communication?

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?