A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?
Reference Range:
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.
The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl (10.8 mmol/L).
The client with an Ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
The Correct Answer is D
Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.
Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.
Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.
Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: While Magnet status can enhance a hospital's reputation and attract patients, the primary purpose of seeking Magnet status is to acknowledge and validate the quality of nursing care, rather than primarily serving as a marketing tool.
Choice B rationale: While Magnet status may contribute to attracting highly qualified nursing staff, the primary focus is on recognizing and promoting excellence in patient care, not specifically on the recruitment of nurses with a particular educational background.
Choice C rationale: Magnet status is not primarily focused on the breadth of services a facility provides. Instead, it is centered on the quality and excellence of nursing care.
The designation does not necessarily indicate the quantity or variety of services offered by a healthcare facility.
Choice D rationale: Magnet status is a designation granted by the American Nurses Credentialing Center (ANCC) to healthcare organizations that demonstrate excellence in nursing practice and outstanding patient care. It signifies that the facility has met rigorous standards for nursing quality, professionalism, and overall commitment to delivering exceptional care to patients.
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.
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