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 C

Explanation

Choice A reason: The black category in the START triage system is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is not in that category since they are conscious and breathing.

Choice B reason: The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is experiencing significant respiratory distress, which categorizes them as more urgent.

Choice C reason: The red category is for clients who need immediate life-saving intervention. This client's respiratory rate of 36 and shortness of breath indicate a severe respiratory distress that requires urgent medical attention.

Choice D reason: The yellow category is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. This client's condition is more severe and needs prompt intervention.

A. Battery B. Assault C. False imprisonment D. Invasion of privacy

Correct Answer is B

Explanation

Choice A reason: Battery involves harmful or offensive physical contact with another person. In this scenario, no physical contact has been made, so the UAP's actions do not constitute battery.

Choice B reason: Assault occurs when a person intentionally creates a reasonable apprehension of imminent harmful or offensive contact in another person. By threatening the client with being put in a diaper if he does not comply, the UAP is creating a fear of potential harm, which constitutes assault.

Choice C reason: False imprisonment involves the unlawful confinement of a person without their consent. While the UAP's threat is inappropriate, it does not involve actual confinement, so false imprisonment is not applicable in this situation.

Choice D reason: Invasion of privacy occurs when there is an intrusion into a person's private affairs or disclosure of private information without consent. The UAP's actions do not involve disclosing private information or intruding into the client's personal life, so invasion of privacy is not relevant here.

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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

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personnel (UAP) reprimanding a client for not using the urinal properly. The UAP tells him that he will be put in a diaper if he does not use the urinal more carefully next time. Which of the following torts is the UAP committing?

Correct Answer is B

Explanation

The nurse educator is reviewing the role of a nurse advocate with a group of newly hired nurses to the hospital. Which of the following statements indicate the newly hired nurses understand the roles of a nurse advocate? (Select All That Apply)

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

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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?