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 C

Explanation

Choice A rationale: This statement is inaccurate. Managed healthcare plans typically cover in-hospital medical evaluations, but the decision may be subject to precertification requirements.

Choice B rationale: While grief is a natural response to the loss of a spouse, the client's confusion and disorientation warrant a medical evaluation, and this option dismisses the family's concerns.

Choice C rationale: Managed care providers often have mandatory precertification requirements for hospitalization. Informing the family about this requirement is important for them to navigate the process effectively.

Choice D rationale: This statement does not provide relevant information about the managed healthcare plan's policies or the client's current condition.

A. Client's healthcare power of attorney. B. Increasing confusion of the client. C. Currently prescribed medications. D. Fall at home as reason for admission.

Correct Answer is B

Explanation

Choice A rationale: The assessment is the client's signed power of attorney and a home medication list, which are important documents that indicate the client's wishes and potential drug interactions. While the client's healthcare power of attorney is important information, the reason for admission should be provided first to give context to the situation.

Choice B rationale: The nurse should start by presenting the immediate situation or concern, which is the client's increasing confusion which needs immediate attention. Choice C rationale: The recommendation is the nurse's suggestion for further diagnostic tests, interventions, or referrals based on the situation, background, and assessment. The currently prescribed medications are relevant, but the primary reason for admission should be communicated first to establish the context of the client's condition. Choice D rationale: The background is the fall at home as the reason for admission, which explains the possible cause of the confusion and the loss of consciousness. This comes after the situation which is the increasing confusion.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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