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 C
Explanation
Choice A rationale: Administering two medications to the same client at the wrong time is a serious error, but it may not be the most critical issue for reporting to the Peer Review Committee (PRC).
Choice B rationale: Changing work assignments without prior approval may be a workplace issue but does not directly endanger patient safety, so it may not be the primary focus of the PRC.
Choice C rationale: Serving a diet tray to a client who is NPO is a serious error that can lead to complications and warrants reporting to the PRC.
Choice D rationale: Documenting data in the clinical record before assessing the client's condition may indicate a documentation error, but it does not pose an immediate risk to the patient's well-being.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale: Consulting with the registered dietitian involves clinical judgment and collaboration with another healthcare professional, which is not within the scope of practice for the UAP.
Choice B rationale: Maintaining a clean and pleasant environment during meals is a task that can be delegated to the UAP to enhance the client's dining experience. Choice C rationale: Setting up the food and drink containers within easy reach is a task that the UAP can perform to facilitate the client's access to meals.
Choice D rationale: Offering specific dietary recommendations, such as high-caloric foods, requires knowledge of nutritional needs, which is beyond the UAP's scope. Choice E rationale: Assisting the client with eating small frequent high-calorie meals is a task that can be delegated to the UAP to support the client's nutritional intake.
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