The nurse receives change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm sized dark red drainage.
A client who fell from a ladder and has a collapsed left lower lung with 100 ml drainage in a chest tube collection container.
A client who is post-mastectomy 2 days ago and has 50 ml of serosanguineous fluid in a Jackson-Pratt drain.
A client who had an abdominal perineal resection 3 days ago and has no drainage on the dressing and is reporting chills.
The Correct Answer is B
Choice A rationale: While the client with the gunshot wound requires attention, the client with a collapsed left lower lung and 100 ml drainage in a chest tube collection container is at immediate risk for respiratory compromise.
Choice B rationale: The client who fell from a ladder with a collapsed left lower lung and 100 ml drainage in a chest tube collection container requires the most immediate intervention to address potential respiratory distress.
Choice C rationale: The client post-mastectomy with 50 ml of serosanguineous fluid in a Jackson-Pratt drain may need attention, but the respiratory distress in the other client takes precedence.
Choice D rationale: The client who had an abdominal perineal resection with no drainage on the dressing and reporting chills may require attention, but the respiratory distress in the other client is a more urgent concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Recording the client's pulse volume distal to the IV site is a nursing responsibility as it involves an assessment of circulation.
Choice B rationale: Reapplying cold compresses is a task that UAP can perform to help minimize swelling and discomfort at the extravasation site.
Choice C rationale: Disposing of the IV tubing after the infusion is discontinued is a nursing responsibility to ensure proper disposal and prevent contamination.
Choice D rationale: Teaching the client about the need to keep the extremity elevated involves patient education and is within the scope of nursing practice.
Correct Answer is A
Explanation
Choice A rationale: The immediate priority during a fire alarm is to ensure the safety of clients and staff. Instructing everyone to stay in the client rooms with doors closed helps contain any potential smoke or fire, providing protection while the situation is assessed.
Choice B rationale: Instructing family members to stay in the waiting area might not be the primary concern during a fire alarm. The focus is on the safety of clients and staff.
Choice C rationale: While determining the nature of the emergency is important, taking immediate actions to ensure safety is the priority. The charge nurse can address the cause once the safety of individuals is secured.
Choice D rationale: Evacuating clients should only be considered if it is determined to be safe to do so. It's crucial to assess the situation and follow established protocols before initiating evacuation.
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