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 ["B","C","D","E","F","G"]

Explanation

Choice A rationale:

Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.

Choice B rationale:

The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.

Choice C rationale:

Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.

Choice D rationale:

A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.

Choice E rationale:

Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.

Choice F rationale:

Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.

Choice G rationale:

A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.

A. Place a pulse oximeter on the client's finger. B. Establish a patent airway for the client. C. Check the client's pulse rate. D. Administer oxygen to the client.

Correct Answer is B

Explanation

Choice A rationale:

Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.

Choice B rationale:

Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.

Choice C rationale:

Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.

Choice D rationale:

Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","E","F","G"]

Explanation

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations.Which of the following is the priority action by the nurse?

Correct Answer is B

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?