The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?

A 32-year-old male admitted yesterday with a femur fracture in traction.

A 38-year-old female with a grade 1 liver laceration admitted 2 days ago.

A 41-year-old male with 4 rib fractures, pneumothorax, and chest tube admitted last night.

A 55-year-old female admitted 6 days ago with a chest contusion from a fall scheduled for discharge today.

Answer and Explanation

The Correct Answer is C

Choice A reason: A 32-year-old male with a femur fracture in traction is stable but needs ongoing pain management and monitoring for complications like infection or deep vein thrombosis (DVT). While this client requires attention, they are not in immediate critical condition compared to other patients on the list.

Choice B reason: A 38-year-old female with a grade 1 liver laceration admitted 2 days ago also requires close observation for signs of bleeding or worsening liver function. However, given that the liver laceration is of a lesser severity (grade 1), the immediate priority is less critical compared to a client with respiratory compromise.

Choice C reason: A 41-year-old male with 4 rib fractures, pneumothorax, and a chest tube is the highest priority. The presence of pneumothorax indicates a potential life-threatening condition that requires close monitoring to ensure the chest tube is functioning correctly and the lung is re-expanding. Any compromise in the chest tube's functionality can lead to respiratory distress or failure, making this client the most critical and requiring immediate assessment.

Choice D reason: A 55-year-old female admitted 6 days ago with a chest contusion and scheduled for discharge today is likely stable and does not have the same level of urgency as a client with a pneumothorax. This client needs final evaluations and discharge planning, but their condition does not present an immediate life-threatening risk.

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

Explanation

Choice A reason: The acuity level of the clients is a critical factor to consider when planning staff assignments. Clients with higher acuity levels require more intensive care and monitoring, necessitating a greater allocation of resources and experienced staff. By considering client acuity, the charge nurse can ensure that the most critical patients receive the appropriate level of care and attention, while also balancing the workload among the nursing staff.

Choice B reason: The clustering of the rooms on the unit can significantly impact the efficiency of care delivery. By grouping clients in close proximity, the nurse can minimize the time and effort spent moving between rooms, thus enhancing the ability to respond quickly to client needs. This consideration helps to optimize workflow and improve overall patient care by reducing potential delays.

Choice C reason: Considering both client needs and the staff's needs and abilities ensures that the right personnel are assigned to the appropriate tasks. Matching staff competencies with client requirements maximizes the effectiveness of care delivery. Additionally, taking into account staff preferences and skills can improve job satisfaction and performance, ultimately benefiting the clients.

Choice D reason: The number of anticipated client discharges is an important logistical factor that can affect the day's workflow. Planning for discharges allows the charge nurse to allocate resources for discharge planning, patient education, and follow-up care. It also helps in managing bed availability and preparing for incoming admissions, ensuring a smooth transition for both clients and staff.

Choice E reason: Specific requests from the staff can include preferences for certain shifts, working with particular patients, or avoiding specific tasks. While it may not always be possible to accommodate all requests, considering them when feasible can improve staff morale and cooperation. Addressing staff preferences helps to create a positive work environment, leading to better teamwork and patient outcomes.

A. When the procedure or treatment will be done. B. The purpose of the proposed treatment or procedure. C. The expected outcomes of the proposed treatment or procedure. D. Who will perform the treatment or procedure. E. An explanation of possible risks from the treatment or procedure.

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

Explanation

Choice A reason: Informing the client when the procedure or treatment will be done is crucial for obtaining informed consent. This information helps the client understand the timeline and schedule for the procedure, which is essential for their planning and mental preparation. Knowing the exact date and time also allows the client to arrange for any necessary assistance or support they might need before and after the procedure.

Choice B reason: The purpose of the proposed treatment or procedure must be clearly explained to the client. This information helps the client understand why the procedure is necessary and what it aims to achieve. Providing a clear rationale for the treatment ensures that the client is fully aware of the medical reasons behind the procedure, which is a fundamental aspect of informed consent.

Choice C reason: The expected outcomes of the proposed treatment or procedure should be discussed with the client. This includes both the potential benefits and the goals of the treatment. By understanding the expected outcomes, the client can make an informed decision about whether to proceed with the procedure, weighing the potential benefits against the risks and alternatives.

Choice D reason: Identifying who will perform the treatment or procedure is an essential component of informed consent. The client has the right to know the qualifications and expertise of the healthcare professional who will be performing the procedure. This information helps build trust and ensures the client feels confident in the care they will receive.

Choice E reason: An explanation of the possible risks from the treatment or procedure is necessary for obtaining informed consent. Clients must be fully informed about the potential risks and complications associated with the procedure so that they can make an educated decision about whether to proceed. This transparency is critical for respecting the client's autonomy and ensuring they are fully aware of all aspects of their care.

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The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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)

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

Explanation

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)

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

Explanation

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