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
A) This intervention is not appropriate because it violates the client's privacy and confidentiality. The health department does not need to be notified of the client's condition, as breast cancer is not a communicable disease or a public health threat. The nurse should respect the client's wishes and only share information with authorized persons or agencies.
B) This intervention is appropriate because it respects the client's autonomy and encourages informed decision-making. The nurse should advise the client to consider the benefits and risks of disclosing or withholding the diagnosis from the family, and how it may affect their relationships and support systems. The nurse should also provide relevant information and resources to help the client make an informed choice.
C) This intervention is not appropriate because it contradicts the client's decision and may cause confusion or distress for the family. The nurse should not suggest genetic screening to the family without the client's consent, as this may imply that they are at risk of developing breast cancer or other genetic disorders. The nurse should also avoid giving unsolicited advice or opinions that may interfere with the client's autonomy.
D) This intervention is not appropriate because it imposes the nurse's values and beliefs on the client. The nurse should not explain that the family has a right to know of potential health problems, as this may imply that the client is wrong or selfish for withholding the diagnosis. The nurse should acknowledge and respect the client's perspective and preferences, and support them in coping with their condition.
Correct Answer is B
Explanation
A) This client has a mild fever, which may indicate an infection or inflammation. This is a potential complication of enteral feedings, but it is not the most urgent situation. The nurse should monitor the client's vital signs, assess the feeding tube site, and notify the provider if the fever persists or worsens.
B) This client has signs of uremic encephalopathy, which is a life-threatening condition caused by the accumulation of toxins in the brain due to impaired renal function. The nurse should intervene immediately to prevent further
neurological damage and possible coma or death. The nurse should assess the client's level of consciousness, check the blood pressure and urine output, and prepare to administer dialysis or other treatments as ordered by the provider.
C) This client has heat stroke, which is a serious condition that can lead to dehydration, electrolyte imbalance, and organ damage. However, the client is receiving a normal saline IV fluid bolus, which is an appropriate intervention to restore fluid volume and correct sodium levels. The nurse should continue to monitor the client's vital signs, skin
temperature, and urine output, and watch for signs of fluid overload or cerebral edema.
D) This client has hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, malnutrition, and electrolyte imbalance. However, the client is receiving an infusion of Ringer's Lactate, which is an isotonic solution that can replenish fluid and electrolyte losses. The nurse should continue to monitor the client's vital signs, weight, and intake and output, and administer antiemetics or other medications as ordered by the provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today