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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Discussing with the family about placing the client in a skilled care facility may be a consideration, but it's not the most immediate concern. Choice B rationale: Determining if the client is manifesting other neurologic changes is crucial to identify potential complications or underlying issues causing the agitation.

Choice C rationale: Requesting family members to report when the client is left alone is important for safety but doesn't address the immediate assessment of the client's condition.

Choice D rationale: Applying a restraining device to prevent the client from self-injury is not the first choice and should only be considered if there's an immediate threat to the client's safety or the safety of others.

A. Instruct the UAP to ask the visitor to get off the client's bed. B. Discuss why visitors should not lie in the bed with the client. C. Explain that the client has the right to have a visitor lie on the bed. D. Notify the charge nurse that the visitor is lying on the client's bed.

Correct Answer is C

Explanation

Choice A rationale: Instructing the UAP to ask the visitor to get off the client's bed is not within the UAP's scope of practice and may cause conflict.

Choice B rationale: While education about infection control and respect for the client's environment is important, it's essential to prioritize the client's autonomy and preferences regarding their visitors.

Choice C rationale: Clients have rights to decide who can be in their personal space, including their bed. As long as the visitor is not posing a risk to the client's safety or health, the client's wishes should be respected.

Choice D rationale: Notifying the charge nurse about the visitor lying on the bed is a reasonable action, but the immediate intervention is to ask the visitor to get off the bed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

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?

After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?

A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?

The nurse-manager overhears a nurse complaining to a co-worker about the time being required to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?

The nurse is caring for an older adult who was admitted with a urinary tract infection and is now exhibiting signs of severe inflammatory response syndrome (SIRS). Which collaborative care goal(s) should the nurse include in the plan of care? Select all that apply.