A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?
The emergency department nurse is waiting to give report on a new admission.
Two staff members have called to say they will be absent.
Transport assistance is unavailable to take a client to occupational therapy.
A nurse on the previous shift wrote an incident report about a medication error.
The Correct Answer is A
Choice A reason: This is the correct choice because this situation is the most urgent and requires immediate action. The charge nurse should prioritize the new admission and assign a staff nurse to receive the report and prepare the room for the client. The charge nurse should also ensure that the client's needs are met and that the admission process is smooth and efficient.
Choice B reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should plan the staffing for the shift and arrange for replacements or reassignments if necessary. The charge nurse should also communicate with the staff members who called in and document their reasons for absence.
Choice C reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should coordinate with the transport department and the occupational therapy department to reschedule the client's appointment or find an alternative way to transport the client. The charge nurse should also inform the client and the staff nurse about the change and apologize for any inconvenience.
Choice D reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should review the incident report and follow up with the nurse who wrote it and the client who was involved. The charge nurse should also implement corrective actions and preventive measures to avoid similar errors in the future.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Contacting the client's next of kin to obtain consent for treatment is not a correct action, as it may delay the necessary and urgent care for the client. The nurse should assume that the client would consent to life-saving treatment and act in the client's best interest.
Choice B reason: Proceeding with treatment without obtaining written consent is the correct action, as it is justified by the emergency doctrine. The nurse should provide immediate and appropriate care for the client who is unable to give consent due to their condition.
Choice C reason: Having the client sign a consent for treatment is not a correct action, as the client is disoriented and cannot give informed consent. The nurse should not ask the client to sign any documents that they may not understand or remember.
Choice D reason: Notifying risk management before initiating treatment is not a correct action, as it is not a priority in an emergency situation. The nurse should focus on the client's needs and safety and document the care provided and the rationale for the actions taken.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the most urgent and potentially life-threatening problem. Urinary retention after spinal surgery can lead to bladder distension, infection, renal damage, or autonomic dysreflexia (a dangerous rise in blood pressure and heart rate). The nurse should assess the client's bladder, catheterize the client if indicated, and notify the surgeon.
Choice B reason: This is not the correct choice because this client has a serious but not urgent problem. Pancreatic cancer is a malignant tumor that can affect the function of the pancreas and other organs. IV chemotherapy is a treatment that uses drugs to kill cancer cells. The nurse should provide emotional support, education, and symptom management to this client, but they are not the highest priority.
Choice C reason: This is not the correct choice because this client has a chronic but not acute problem. Peripheral vascular disease is a condition that affects the blood vessels outside the heart and brain, causing reduced blood flow to the limbs. An absent pedal pulse indicates poor circulation in the foot, which can lead to pain, numbness, or tissue damage. The nurse should monitor the client's pulses, skin temperature, and color, and teach the client how to prevent complications, but they are not the highest priority.
Choice D reason: This is not the correct choice because this client has a stable but not critical problem. MRSA is a type of bacteria that is resistant to many antibiotics and can cause skin or systemic infections. An axillary temperature of 38°C (101°F) indicates a mild fever, which is a common sign of infection. The nurse should administer antibiotics as prescribed, observe the client for signs of sepsis, and follow infection control precautions, but they are not the highest priority.
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