The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the health care provider?

The charge nurse

The nursing assistant

The nurse

The client

Answer and Explanation

The Correct Answer is C

A. The charge nurse: While the charge nurse may assist in overseeing patient care, the responsibility for reporting changes in a specific patient's condition lies with the nurse assigned to that patient. Delegation does not remove the accountability of the primary nurse.

B. The nursing assistant: Nursing assistants are not licensed to interpret or report critical changes in a patient's condition. They may measure vital signs but must report abnormal findings to the licensed nurse, who is responsible for further action.

C. The nurse: The nurse caring for the client is ultimately responsible for assessing the situation, interpreting the data, and notifying the healthcare provider. Timely communication of significant changes in condition is a key nursing responsibility.

D. The client: Although the client may express concern about symptoms, it is not their responsibility to report changes to the provider. It is the nurse’s duty to act on clinical findings and initiate communication with the medical team.

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Correct Answer is A

Explanation

A. double verify with a licensed personnel: Insulin is a high-alert medication with a narrow therapeutic window and a significant risk of causing serious harm if dosed incorrectly, including severe hypoglycemia. Double verification with another licensed healthcare professional ensures accurate dosing and enhances patient safety.

B. monitor intake and output: Monitoring intake and output is important for assessing fluid balance and kidney function but does not directly influence the safe administration of insulin or prevent dosing errors related to blood glucose control.

C. assess vital signs: While vital signs such as heart rate and blood pressure are important in overall patient assessment, they do not directly prevent insulin administration errors or detect hypoglycemia before it occurs.

D. give with orange juice to promote absorption: Orange juice is used to treat hypoglycemia due to its sugar content but does not promote insulin absorption. Insulin absorption is primarily influenced by injection site and technique, not concurrent food or drink intake.

A. Laceration sealed with adhesive B. Skin tear on the forearm C. Stapled hip incision D. Stage 4 pressure injury E. Infected re-opened abdominal incision

Correct Answer is ["B","D","E"]

Explanation

A. Laceration sealed with adhesive: This wound is healing by primary intention, where the wound edges are approximated and closed using sutures, staples, or adhesive. Healing is typically faster with minimal scarring and reduced risk of infection.

B. Skin tear on the forearm: A skin tear often involves partial loss of skin integrity and may not have edges that can be approximated. When left open to heal naturally, it undergoes secondary intention, which involves granulation tissue formation, contraction, and epithelialization.

C. Stapled hip incision: This wound is healing by primary intention because the edges have been brought together and secured using staples. There is minimal tissue loss and faster healing with less scarring compared to secondary intention.

D. Stage 4 pressure injury: A stage 4 pressure injury involves full-thickness tissue loss that often exposes muscle, tendon, or bone. Due to extensive tissue damage and inability to approximate wound edges, it heals by secondary intention through granulation and scar tissue formation.

E. Infected re-opened abdominal incision: If a surgical incision becomes infected and dehisces, it can no longer heal by primary intention. It must be managed as an open wound, healing by secondary intention, involving a longer healing process and greater risk of scarring.

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The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is giving sub-Q insulin. A major nursing responsibility prior to administration of this category of drugs is to:

Correct Answer is A

Explanation

A WOCN is reviewing the wound healing process with a group of nurses on a unit. The WOCN should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

A patient has had diarrhea for several days. What assessment will the nurse make to identify risks from the diarrhea?

In the delivery of care the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value?

A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?

The nurse awakens a client while the client is experiencing rapid eye movement sleep. What statement made by the client indicates they were awakened during REM sleep?

A client weighs 165 lb. She has a medication prescribed with a maximum daily dosage of 60 mg/kg/day. What is the maximum number of milligrams this this client can receive/day? (TYPE NUMBERS ONLY: Round to nearest whole number, Use commas as appropriate.)

A nurse is reviewing the routes of medication administration. Place the routes in order from fastest to slowest rate of absorption.

A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?