A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Set target dates for completion.

Identify areas of support.

Determine goals and objectives.

Implement recommended strategies.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.

Choice B rationale:

Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.

Choice C rationale:

Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.

Choice D rationale:

Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.

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Correct Answer is B

Explanation

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

A. Assess the client's incision every 8 hours for the first 48 hours. B. Inform the assistive personnel of the client's weight-bearing status. C. Instruct the client to cross their legs at the ankles when sitting in a chair. D. Teach the client's partner to assist the client to flex the hip at least 120° each hour.

Correct Answer is B

Explanation

The correct answer is b. Inform the assistive personnel of the client’s weight-bearing status.

Choice A: Assess the client’s incision every 8 hours for the first 48 hours. While it is important to monitor the incision site for signs of infection, the frequency of every 8 hours for the first 48 hours may not be necessary unless specified by the surgeon or the patient’s condition warrants it.

Choice B: Inform the assistive personnel of the client’s weight-bearing status. This is the correct answer. After a total hip arthroplasty, it’s crucial to communicate the client’s weight-bearing status to all members of the healthcare team, including assistive personnel. This helps ensure that everyone is aware of the client’s mobility limitations and can assist the client safely.

Choice C: Instruct the client to cross their legs at the ankles when sitting in a chair. This is not recommended. After a hip arthroplasty, patients are typically advised not to cross their legs to prevent dislocation of the new hip joint.

Choice D: Teach the client’s partner to assist the client to flex the hip at least 120° each hour. This is not recommended. After a hip arthroplasty, patients are typically advised to avoid flexing the hip more than 90 degrees to prevent dislocation of the new hip joint1. Therefore, flexing the hip at least 120° each hour could potentially harm the patient.

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A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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