A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?
A client who reports a severe migraine headache
A client who has a suspected diagnosis of tuberculosis (TB)
A client who sustained a head injury and is having periods of confusion
A client who has a history of atrial fibrillation and is on continuous ECG monitoring.
The Correct Answer is C
A. While a severe migraine headache is certainly uncomfortable and may require medication and observation, it does not typically necessitate constant monitoring. The client might benefit from a quieter room and can often be managed effectively with scheduled visits by nursing staff. Therefore, this client does not necessarily need to be closest to the nurses' station.
B. A client with a suspected diagnosis of TB should be placed in a negative-pressure isolation room to prevent the spread of airborne pathogens. The proximity to the nurses' station is less critical for infection control purposes. Proper isolation procedures and equipment are more important for managing TB.
C. A client with a head injury and periods of confusion is at risk for complications such as falls, disorientation, or worsening of their condition. This client requires close monitoring to ensure their safety and to promptly address any changes in their condition. Assigning this client to a room closest to the nurses' station ensures that the staff can frequently observe and quickly respond to any potential issues.
D. A client on continuous ECG monitoring requires regular assessment of their heart rhythm and immediate intervention if there are any abnormalities. While close monitoring is needed, this client’s condition is managed with electronic equipment that can alert staff to significant changes, so proximity to the nurses' station is less critical compared to more acute or unpredictable conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This is a professional and important action. Ensuring that a client is competent to consent means that the nurse is verifying that the client understands the nature, purpose, risks, and benefits of the procedure. Competence to consent is a legal and ethical requirement, and it is part of the nurse’s role to support and facilitate the informed consent process.
B. This is also a professional and necessary action. It involves checking that the client’s consent is given freely, without coercion or undue pressure. This step ensures that the consent is valid and ethical. It is part of the nurse's responsibility to ensure that the consent process respects the client's autonomy.
C. The nurse as a witness is there to observe that the consent is signed by the client and that the client understands what they are consenting to. However, the nurse should not be the one explaining the procedure or the risks involved unless they are specifically trained and authorized to do so.
D. This is generally not considered professional behavior for a nurse unless they have specific training and authorization to provide detailed information about surgical procedures. Typically, detailed explanations of the procedure are provided by the surgeon or a qualified healthcare provider.
Correct Answer is B
Explanation
A. While delegation might contribute to more efficient use of resources and potentially reduce some costs, it is not the primary purpose of delegation. The main goal of delegation is to manage tasks and responsibilities more effectively, rather than focusing directly on cost reduction.
B. Delegation involves assigning specific tasks or responsibilities to others so that goals can be met more efficiently. It allows the delegating nurse to entrust certain tasks to others, enabling the overall objectives of patient care and unit management to be achieved effectively. This statement captures the essence of delegation as it involves empowering others to carry out tasks to achieve a common goal.
C. While delegation can help ensure that resources are used appropriately by assigning tasks to the right individuals, this statement is more about resource management rather than the primary purpose of delegation itself.
D. Delegation itself does not specifically promote discharge teaching activities. While tasks related to discharge teaching can be delegated, the primary purpose of delegation is broader, focusing on managing workload and achieving goals by assigning tasks to others.
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