A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?

"I have my assignment and will start with room 1, then work my way to room 10."

"After breakfast, I will pack the belongings of clients who will be discharged this morning."

"I will start by providing partial baths before breakfast."

"I will give this client his meal tray first, as he is going early to physical therapy."

Answer and Explanation

The Correct Answer is A

Rationale:

A. Starting with room 1 and working to room 10 suggests a lack of prioritization based on client needs, which is important for efficient and effective care.

B. Packing belongings after breakfast is a reasonable plan, assuming it fits within the priorities of the shift.

C. Providing partial baths before breakfast might be acceptable depending on the client’s needs and the urgency of the task.

D. Giving a client their meal tray first based on their scheduled physical therapy is an example of prioritizing care based on client needs.

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Correct Answer is C

Explanation

Rationale:

A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.

B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.

C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.

D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.

A. A client who has COPD and the capillary refill time on both hands is 4 seconds B. A client who has late-stage cirrhosis and whose breath has a fruity odor C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided

Correct Answer is D

Explanation

Rationale:

A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.

B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.

C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.

D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.

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A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is D

Explanation

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