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 D

Explanation

The correct answer is: d. Location of the identification tag on the client’s body.

Choice A reason: The cause of the client’s death is determined by a physician or a medical examiner and is not typically documented by nurses in postmortem documentation. The cause of death is a medical determination that involves a complex process, including examination and possibly an autopsy.

Choice B reason: The last set of the client’s vital signs is relevant prior to death and is part of the end-of-life documentation. However, once the client has passed away, recording vital signs is no longer applicable and is not included in postmortem documentation.

Choice C reason: A copy of the client’s advance directives is an important document that outlines the client’s wishes regarding medical treatment and interventions. While it is crucial before the client’s death, it does not need to be included in postmortem documentation, as it serves no purpose after death.

Choice D reason: The location of the identification tag on the client’s body is a critical piece of information that must be included in postmortem documentation. This ensures that the body is correctly identified throughout the postmortem process, including during transfer to a mortuary or funeral home.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

The correct answer is choice A: Fat embolism syndrome.

Choice A rationale:

The client with an open fracture to the right femur is at risk for developing Fat Embolism Syndrome (FES) FES occurs when fat globules from the bone marrow or other tissues enter the bloodstream, leading to systemic complications. In this case, with an open fracture, there is a higher risk of fat emboli entering the circulation. The clinical manifestations of FES include respiratory distress, altered mental status, and petechial rash. These symptoms typically occur within 24-72 hours after the injury, which aligns with the timeline mentioned in the progress report on Day 1 of admission.

Choice B rationale:

Osteomyelitis is less likely to develop within the first 24 hours following a motor vehicle crash. It is an infection of the bone and typically takes more time to manifest. The early concerns in an open fracture involve the risk of infection, but osteomyelitis is not an immediate threat in this scenario.

Choice C rationale:

Compartment syndrome is a potential concern in orthopedic injuries, but it primarily arises due to increased pressure within a muscle compartment, causing reduced blood flow. While it is a valid concern, it is not typically associated with fat embolism syndrome, which is more specific to the release of fat globules into the bloodstream.

Choice D rationale:

Deep vein thrombosis (DVT) is a concern in immobile patients or those with significant trauma, but it is not the most immediate concern in this case. DVT usually develops over time and is more associated with prolonged immobilization rather than the early stages of admission.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client on an orthopedic unit. Exhibits Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

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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?