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. Educators typically disseminate knowledge to others, but they don't necessarily collect data to generate new knowledge.
B. Advocates primarily support and defend the rights or interests of others. While this can involve data collection, it's not the primary focus in this scenario.
C. Mentors provide guidance and support to individuals, but they are not typically involved in research or data collection.
D. Researchers systematically collect and analyze data to answer questions and contribute to knowledge. In this case, the nurse is conducting research to determine the best practices for reducing pressure injuries.
Correct Answer is D
Explanation
A. Monitoring blood glucose is crucial for managing diabetes, as it directly affects the child's blood sugar levels and overall well-being. However, if the child’s blood glucose levels are stable and there are no immediate concerns or symptoms, this task, while important, may not be as urgent as assessing more critically ill clients.
B. While discharge instructions are important for ensuring proper care after leaving the hospital, this task generally does not require immediate attention compared to assessing a client with more acute or urgent needs. The adolescent is ready for discharge, indicating their condition is stable enough to prepare for leaving the unit.
C. Feeding a toddler who has both arms in casts is important for ensuring that the child is well-nourished and comfortable. However, this task can usually be managed by assistive personnel or done at a scheduled time without immediate urgency compared to more critical assessments.
D. An infant with pertussis (whooping cough) receiving oxygen via nasal cannula is in a potentially critical situation. Pertussis can cause significant respiratory distress, and the need for oxygen indicates the
infant’s respiratory function is compromised. Assessing this infant first is crucial to ensure that the oxygen therapy is effective and to monitor for any signs of deterioration in respiratory status.
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