A nurse is caring for four clients. Which of the following assessment findings is the priority?

A client who has facial drooping following a stroke 8 hours ago.

A client who has a femur fracture and reports feeling short of breath.

A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10.

A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.

Choice A rationale:

A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.

Choice B rationale:

A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.

Choice C rationale:

A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.

Choice D rationale:

A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.

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Correct Answer is B

Explanation

Choice A rationale:

Showing the AP how to remove an indwelling urinary catheter may not provide sufficient evidence of their competency to perform the task safely and effectively. This approach assumes that observation alone is enough to determine competence, which is not necessarily the case. It's important to have a more structured assessment of the AP's skills.

Choice B rationale:

Reviewing the AP's skill competency checklist is the most appropriate action to ensure the AP is qualified to remove the indwelling urinary catheter. Competency checklists outline specific skills and steps required for a task, and they serve as a standardized way to assess the AP's capabilities. This process ensures that the AP has received proper training and has demonstrated competence before performing the procedure independently.

Choice C rationale:

Simply asking the AP if they know how to remove an indwelling urinary catheter is not a comprehensive method for verifying their qualifications. Self-assessment can be unreliable and may not accurately reflect the AP's actual skill level. Relying solely on self-reporting could compromise patient safety and quality of care.

Choice D rationale:

Pairing the newly hired AP with an experienced AP might provide some guidance, but it doesn't systematically assess the individual's competence. The level of experience of the experienced AP may vary, and their ability to teach or evaluate the new AP's skills may not be standardized.

A. Inform the staff of the penalties that can result from medication errors. B. Encourage the staff to have two nurses verify medication orders to prevent errors. C. Provide a suggestion box for the staff to submit ideas for error prevention. D. Ask three experienced nurses to help investigate common causes of the errors.

Correct Answer is A

Explanation

Choice A rationale:

Informing the staff of the penalties that can result from medication errors represents an authoritarian approach to managing the issue. This approach relies on authority and fear to enforce compliance. By emphasizing the potential consequences, the nurse manager is attempting to control behavior through fear of punishment. While this might create a short-term change in behavior, it does not address the root causes of the errors or promote a culture of safety.

Choice B rationale:

Encouraging the staff to have two nurses verify medication orders to prevent errors is not an authoritarian approach. It involves collaboration and peer support to enhance medication safety. This approach promotes shared responsibility and accountability, which are not associated with authoritarian leadership.

Choice C rationale:

Providing a suggestion box for the staff to submit ideas for error prevention is not an authoritarian approach. This strategy fosters a participative and democratic leadership style. It encourages staff engagement and input, which contrasts with the top-down nature of authoritarian leadership.

Choice D rationale:

Asking three experienced nurses to help investigate common causes of the errors is not an authoritarian approach. It involves a collaborative and problem-solving approach that seeks input from knowledgeable staff members. This approach aims to identify systemic issues contributing to errors rather than focusing solely on punitive measures.

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A nurse is caring for four clients. Which of the following assessment findings is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Correct Answer is B

Explanation

A nurse manager needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing this issue?

Correct Answer is A

Explanation

A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behaviors should the charge nurse identify as an indication that the staff nurse might be working while impaired?

A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)?

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult in planning for this policy?

A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference?

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.).

A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty and speaks a different language than the nurse. Which of the following interprofessional team members should the nurse include in the discussion?