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 A
Explanation
Choice A Reason: This is the best action because it prevents the spread of infection to other clients and staff. Mumps is a viral infection that causes inflammation of the salivary glands and can be transmitted by respiratory droplets. The nurse should place an isolation cart outside of the room and wear a mask, gloves, and gown when entering.
Choice B Reason: This is not the first priority because it does not address the risk of infection. The nurse should schedule bedside play time with the occupational therapist to promote the child's development and coping, but this can be done later.
Choice C Reason: This is not the first priority because it does not ensure that infection control measures are in place. The nurse should instruct the child's parents about the need for transmission precautions and educate them on how to care for their child at home, but this can be done later.
Choice D Reason: This is not the first priority because it does not prevent the spread of infection. The nurse should assign the child to a room close to the nurse's station to monitor his condition and provide comfort, but this is not a critical intervention.
Correct Answer is D
Explanation
Choice A Reason:Notifying the prescriber is essential, but it is secondary to obtaining objective data. The nurse must first secure timely laboratory results to report concrete values. Immediate notification without current coagulation data delays informed decision-making about reversal, dosing changes, or additional interventions.
Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,
hematuria, hematemesis, melena, or epistaxis.
Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an
adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.
Choice D Reason:Rapidly measuring PT/INR and aPTT provides objective evidence of anticoagulation level after dual therapy. These results directly influence urgent clinical decisions, such as holding anticoagulants, administering reversal agents, or preparing for interventions to control bleeding, making this the highest‑priority action.
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