A nurse in a long-term care facility observes an assistive personnel who is incorrectly monitoring a client's blood glucose level.
The nurse should report this observation to which of the following personnel first?

Nurse manager.

Charge nurse.

Risk manager.

Nurse supervisor.

Answer and Explanation

The Correct Answer is B

The correct answer is choice b. Charge nurse.

Choice b rationale: The charge nurse is the appropriate personnel to report the incorrect blood glucose monitoring by the assistive personnel. As the nurse in charge of the unit, the charge nurse has the authority and responsibility to address issues related to patient care and ensure that nursing staff, including assistive personnel, are providing care according to facility policies and procedures

Choice a rationale: While the nurse manager is responsible for overseeing the nursing staff and ensuring quality patient care, it is more appropriate to report the incident to the charge nurse first, as they are directly responsible for the unit and can immediately address the issue

Choice c rationale: The risk manager is responsible for identifying, assessing, and mitigating risks within the healthcare facility. While the incorrect blood glucose monitoring could be considered a risk, it is not the primary role of the risk manager to address issues related to patient care. The charge nurse is better positioned to address the immediate concern and ensure proper training or corrective action for the assistive personnel.

Choice d rationale: The nurse supervisor is responsible for overseeing and managing nursing staff, similar to the nurse manager. However, the charge nurse is the more appropriate personnel to report the incident to, as they are directly responsible for the unit and can immediately address the issue

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Correct Answer is C

Explanation

Choice A rationale:

Rigid abdomen. A rigid abdomen is not typically associated with placenta previa. Placenta previa is a condition in which the placenta partially or completely covers the cervix, and it is more likely to present with painless vaginal bleeding rather than abdominal rigidity.

Choice B rationale:

Persistent uterine contractions. Persistent uterine contractions are not a characteristic finding in placenta previa. In fact, uterine contractions can be concerning in the presence of placenta previa as they may increase the risk of bleeding.

Choice C rationale:

Bright red vaginal bleeding. Bright red vaginal bleeding is a common and hallmark symptom of placenta previa. This bleeding typically occurs without pain and can be intermittent or continuous. It is essential to recognize this symptom promptly because it can lead to significant maternal and fetal complications.

Choice D rationale:

Increased fetal movement. Increased fetal movement is not a typical finding in placenta previa. The presence or absence of fetal movement should always be monitored during pregnancy, but it is not a specific indicator of placenta previa.

A. A client who has cirrhosis and severe pruritus. B. A client who has a femur fracture and reports numbness of the toes. C. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge. D. A client who had a renal biopsy 3 hr ago and has pink-tinged urine.

Correct Answer is B

Explanation

Choice A rationale:

The client with cirrhosis and severe pruritus is experiencing discomfort, but it is not an immediate life-threatening situation. The priority should be given to clients with conditions that pose an immediate risk to life.

Choice B rationale:

Numbness of the toes in a client with a femur fracture can indicate compromised circulation or nerve damage. This is a critical situation that requires immediate assessment and intervention to prevent complications like compartment syndrome or permanent nerve damage.

Choice C rationale:

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable. While they need monitoring, it is not an urgent priority compared to the client with a potential vascular or nerve issue.

Choice D rationale:

Pink-tinged urine after a renal biopsy could indicate some bleeding, but it is not as urgent as the situation of the client with a femur fracture and numbness of the toes.

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A nurse in a long-term care facility observes an assistive personnel who is incorrectly monitoring a client's blood glucose level. The nurse should report this observation to which of the following personnel first?

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A nurse in a long-term care facility observes an assistive personnel who is incorrectly monitoring a client's blood glucose level.
The nurse should report this observation to which of the following personnel first?