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%.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice B rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice C rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice D rationale: This could indicate impaired circulation or nerve compression, which could lead to permanent damage or loss of limb if not treated promptly.

A. Confirm that sexual activity may resume after initial treatment. B. Notify that persons with STIs are reported to local health departments. C. Provide counseling that most contraceptives protect against infection. D. Remain non-judgmental and assure the client of confidentiality.

Correct Answer is D

Explanation

Choice A rationale: Sexual activity should be avoided until the client and all sexual partners have completed treatment and are symptom-free. This is to prevent reinfection and transmission of the STI.

Choice B rationale: Persons with STIs are not reported to local health departments unless they have a reportable disease such as syphilis, gonorrhea, chlamydia or HIV. Trichomoniasis is not a reportable disease in most jurisdictions.

Choice C rationale: Most contraceptives do not protect against infection. The only contraceptive method that provides some protection against STIs is the male or female condom.

Choice D rationale: The nurse should remain non-judgmental and assure the client of confidentiality. This is because the nurse has a professional and ethical obligation to respect the client's autonomy, privacy and dignity.

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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)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

The nurse is caring for a client at the clinic who tests positive for the sexually transmitted infection (STI) trichomoniasis. The client reports having sex with multiple partners. Which response should the nurse provide?

Correct Answer is D

Explanation

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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?

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While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

The charge nurse is providing instructions to an unlicensed assistive personnel (UAP) who will be assisting with the care of a client who has a hiatal hernia. Which instruction should the charge nurse provide the UAP?

An adult client is admitted via the emergency department (ED) with a head injury that will initially require intensive care. Which nurse should be responsible for coordinating the progression of this client's care through rehabilitation and discharge?

A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

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)]