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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Contacting the healthcare provider is not the priority action because restraints should only be used as a last resort and not for staff convenience. The nurse manager should first ensure that the client's safety and dignity are respected.
Choice B Reason: This is the correct answer because restraints are not indicated for this situation and violate the client's rights. The nurse manager should educate the staff nurse about the ethical and legal implications of using restraints without proper justification and documentation.
Choice C Reason: Closing the door to the room is not a priority action because it does not address the issue of restraints. It also may isolate the client and increase her anxiety and distress.
Choice D Reason: Determining if the client has a PRN prescription for an antianxiety agent is not a priority action because it does not address the issue of restraints. It also may not be appropriate to medicate the client without assessing her condition and obtaining her consent.
Correct Answer is ["B","C"]
Explanation
Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.
Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.
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