A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
A client who has pneumonia and has an axillary temperature of 38° C (101° F)
A client who has diarrhea and requests clear liquids for breakfast
A client who has a cast on the left leg and reports numbness and paresthesia
A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Providing appropriate resources is an outcome of effective delegation but not its primary purpose.
B. Promoting discharge teaching is not the primary purpose of delegation; it’s more about ensuring tasks are appropriately assigned.
C. Delegation permits a designated individual to meet a goal on your behalf, accurately reflecting the purpose of delegating tasks to others to achieve client care goals efficiently.
D. Decreasing health care costs may be an indirect benefit, but it is not the primary purpose of delegation.
Correct Answer is C
Explanation
Rationale:
A. Discussing the LPN's behavior with other nurses could potentially lead to gossip and does not address the core issue.
B. The charge nurse does not have authority to review personnel files; this is handled by management or HR.
C.The most appropriate first step is to investigate the client concerns directly. This provides objective information to determine if further action (coaching, reassignment, reporting to management) is necessary.
D. Reassigning client care to assistive personnel does not address the root cause of the problem and may not be an appropriate or effective solution without further investigation.
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