A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

Evaluate why the client was not ambulated.

Ambulate the client on behalf of the AP.

Supervise the AP performing the task.

Remind the AP of her assigned tasks.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.

B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.

C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.

D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.

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Correct Answer is C

Explanation

Rationale:

A. Naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose. It does not provide pain relief and is not appropriate for managing acute exacerbations of chronic pain.

B. Acetaminophen: Acetaminophen is useful for mild to moderate pain but may be insufficient for an acute exacerbation of chronic pain, especially if the client has severe or breakthrough pain.

C. Fentanyl: Fentanyl is a potent opioid analgesic appropriate for managing severe acute pain or acute exacerbations of chronic pain. It acts rapidly to relieve pain and is often used in clients already tolerant to opioids.

D. Zolpidem: Zolpidem is a sedative-hypnotic used to treat insomnia. It does not have analgesic properties and is not indicated for pain management.

A. Hemoglobin and hematocrit B. Stool results C. Temperature D. WBC count E. Respiratory rate F. Heart rate G. Blood pressure H. Current medications

Correct Answer is ["A","B","F","G","H"]

Explanation

Rationale:

A. Hemoglobin and hematocrit: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly below normal, indicating anemia, likely from gastrointestinal bleeding. This finding requires immediate follow-up to prevent further hemodynamic compromise and assess for ongoing blood loss.

B. Stool results: The client reports dark, tarry stool, which is indicative of melena and gastrointestinal bleeding. Positive hemoccult (if confirmed) further supports active bleeding. Prompt evaluation is necessary to identify the source and prevent severe anemia or shock.

C. Temperature: The client’s temperature is 37.5°C (99.5°F), which is mildly elevated but not critically high. It does not indicate an immediate life-threatening condition, though it should be monitored as part of ongoing assessment for infection.

D. WBC count: The WBC is 6,700/mm³, which is within normal limits. There is no indication of acute infection requiring immediate intervention at this time.

E. Respiratory rate: The respiratory rate of 18/min is within normal limits and does not require immediate follow-up.

F. Heart rate: The client’s heart rate is 118/min, which is tachycardic and may indicate hypovolemia from blood loss. Immediate monitoring and intervention are warranted to prevent cardiovascular compromise.

G. Blood pressure: The client’s blood pressure is 90/50 mm Hg, which is hypotensive. This may result from fluid loss due to bleeding and requires urgent assessment and stabilization to prevent shock.

H. Current medications: The client is taking high-dose ibuprofen (800 mg three times daily), a nonsteroidal anti-inflammatory drug (NSAID), which increases the risk of gastrointestinal bleeding and ulcer formation. This directly relates to the client’s presenting symptoms and requires immediate review and discontinuation.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

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A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

Correct Answer is C

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