A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?
A client who has dementia and is experiencing paranoia
A client who has a UTI and reports itching after receiving a dose of cefaclor PO
A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr
A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III
The Correct Answer is B
A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While reviewing previous appraisals may provide some context, it is not the most effective way to evaluate current performance.
B. Gathering information from clients provides direct feedback about the AP’s performance and interactions, making it a valuable input for performance appraisals.
C. Examining the job description is helpful for understanding expectations, but it does not provide specific performance insights needed for an appraisal.
D. Peer reviews can be informative, but they may not reflect the full scope of the AP's duties and interactions with clients, which are critical for a comprehensive performance appraisal.
Correct Answer is D
Explanation
A. Using only room numbers for client identification does not guarantee confidentiality, as room numbers can still be linked to specific individuals.
B. Logging assistive personnel into unit computers compromises security and violates confidentiality protocols. Each user should have a unique login.
C. Including a client’s name on a fax cover sheet is not recommended, as it exposes protected health information and can breach confidentiality.
D. Conducting change-of-shift report in a staff-only area protects client information from being overheard by unauthorized individuals, ensuring confidentiality.
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