A charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?

A client with multisystem failure secondary to a motor vehicle collision.

A client in end-stage liver failure who is experiencing esophageal bleeding.

A client with Adult Respiratory Distress Syndrome who is on a ventilator.

A client with chest tubes secondary to a stab wound to the chest.

Answer and Explanation

The Correct Answer is D

Choice A Reason: A client with multisystem failure secondary to a motor vehicle collision is not an appropriate assignment for the new graduate nurse. This client has complex and unstable needs that require advanced assessment, intervention, and evaluation skills. The nurse should assign this client to a nurse with 10 years experience, who has more expertise and confidence in managing critically ill clients.

Choice B Reason: A client in end-stage liver failure who is experiencing esophageal bleeding is not an appropriate assignment for the new graduate nurse. This client has a high risk of complications such as hemorrhage, infection, hepatic encephalopathy, and hepatic coma. The nurse should assign this client to a nurse with 5 years experience, who has more knowledge and skill in providing palliative care and managing bleeding disorders.

Choice C Reason: A client with Adult Respiratory Distress Syndrome who is on a ventilator is not an appropriate assignment for the new graduate nurse. This client has a life-threatening condition that requires close monitoring of respiratory status, oxygenation, and hemodynamics. The nurse should assign this client to a nurse with 10 years of experience, who has more competence and proficiency in caring for ventilated clients and interpreting data from invasive devices.

Choice D Reason: A client with chest tubes secondary to a stab wound to the chest is an appropriate assignment for the new graduate nurse. This client has a relatively stable condition that requires routine care of chest tubes, pain management, and wound healing. The nurse should assign this client to the new graduate nurse, who has learned the basic principles and techniques of chest tube management during the refresher course and the internship. The charge nurse should also provide supervision and support to the new graduate nurse as needed.

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Correct Answer is D

Explanation

Choice A Reason: This is not the first action because it does not address the safety risk of smoking in the hospital. The nurse should document the occurrence after taking appropriate measures to prevent fire and injury.

Choice B Reason: This is not the first action because it does not stop the client from smoking in the bathroom. The nurse should obtain a prescription for a nicotine patch if the client agrees to quit smoking, but this is not a priority at this time.

Choice C Reason: This is not the first action because it does not ensure that the client will comply with the hospital smoking policy. The nurse should educate the client about the health hazards of smoking and the hospital rules, but this can be done later.

Choice D Reason: This is the best action because it alerts the authority figure who can intervene and enforce the hospital smoking policy. The nurse should notify the charge nurse as soon as possible to prevent fire and injury.

A. A client who had an abdominal-perineal resection 3 days ago has no drainage on the dressing and is reporting chills. B. A client who fell from a ladder and has a collapsed left lower lung with 100 mL drainage in a chest tube collection container. C. A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm-sized dark red drainage. D. A client who is post-mastectomy 2 days ago and has 50 mL of serosanguineous fluid in a Jackson-Pratt drain.

Correct Answer is A

Explanation

Choice A reason: This client may have an infection or sepsis, which are life-threatening complications of surgery. The nurse should assess the client's vital signs, wound appearance, and laboratory results, and notify the physician immediately.

Choice B reason: This client has a chest tube to drain the pleural fluid and re-expand the lung. The amount of drainage is within normal limits and does not indicate an emergency. The nurse should monitor the client's respiratory status, oxygen saturation, and chest tube function.

Choice C reason: This client has a gunshot wound that may have caused tissue damage and bleeding. The dressing with 2 cm-sized dark red drainage may indicate fresh bleeding, but it is not excessive. The nurse should check the dressing for signs of infection, change it as ordered, and report any changes to the physician.

Choice D reason: This client has a Jackson-Pratt drain to collect the fluid from the surgical site after a mastectomy. The amount of serosanguineous fluid is expected and does not indicate a problem. The nurse should empty and measure the drain output, record it, and report any abnormalities to the physician.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The smell of cigarette smoke is coming from a client's bathroom. Which action should the nurse implement first?

Correct Answer is D

Explanation

The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?

Correct Answer is A

Explanation

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

In evaluating a staff nurse who demonstrates inconsistent performance, which intervention should the nurse- manager employ?

When triaging emergency room clients, which client should the nurse assess first?

A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?