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 D
Explanation
Choice A Reason: A subtotal thyroidectomy is a major surgery that involves the removal of part of the thyroid gland. The client may have complications such as bleeding, infection, hypocalcemia, or vocal cord damage. The client also needs close monitoring of vital signs, blood transfusion, and airway patency. This client is not stable enough to be transferred to a general unit.
Choice B Reason: A combined partial and full-thickness burn is a serious injury that involves damage to the epidermis, dermis, and underlying tissues. The client may have complications such as infection, fluid loss, hypovolemia, shock, or respiratory distress. The client also needs wound care, pain management, fluid replacement, and oxygen therapy. This client is not stable enough to be transferred to a general unit.
Choice C Reason: A renal transplant is a major surgery that involves the replacement of a diseased kidney with a healthy one from a donor. The client may have complications such as rejection, infection, bleeding, thrombosis, or urinary obstruction. The client also needs immunosuppressive therapy, anti-infective therapy, fluid and electrolyte balance, and pain management. This client is not stable enough to be transferred to a general unit.
Choice D Reason: Nephrotic syndrome is a kidney disorder that causes excessive protein loss in the urine, leading to low serum protein levels and edema. The client may have complications such as infection, thromboembolism, or malnutrition. The client needs diuretic therapy, protein replacement, dietary modification, and infection prevention. This client is relatively stable and can be transferred to a general unit.
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it helps the client meet their nutritional needs and prevents further weight loss. The nurse should delegate tasks that are within the scope of practice of the UAP, such as feeding assistance.
Choice B Reason: This is not an appropriate action because it requires a nursing assessment and intervention. The nurse should determine if the client is at risk for aspiration and consult with a speech therapist or dietitian before modifying the client's diet.
Choice C Reason: This is not a relevant action because it does not address the nursing problem of altered nutrition. The nurse should monitor the client's respiratory status and oxygenation, but this is not a task that can be delegated to the UAP.
Choice D Reason: This is not a sufficient action because it does not ensure that the client will consume enough food. The nurse should educate the client on the importance of high-protein foods, but this is not a task that can be delegated to the UAP.
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