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A nurse is collaborating with the interprofessional team and reviewing a client's electronic medical record of a post-operative client.

Exhibits

Click to highlight the findings that the nurse should recommend be addressed by the case manager. To deselect a finding, click on the finding again.

Nurses' Notes

1315:

Client is postoperative following an open cholecystectomy. Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment.

Plan of Care

1300:

Case management referral for discharge planning. Client will need home health referral for dressing changes. Client to follow up with the provider at the clinic in one week.

Client's partner is at bedside

dressing intact

small amount of serosanguineous drainage on dressings

reports pain as 5

Client requests a dose of their pain medication

expresses concern regarding the cost of prescription medications

unable to find transportation

home health referral

Answer and Explanation

The Correct Answer is ["D","E","F","G","H"]

Rationale

Client reports pain as 5 on a scale of 0 to 10. The case manager can work with the healthcare team to ensure adequate pain management strategies are in place.
Client requests a dose of their pain medication. This indicates ongoing pain and the need for effective pain management.
Client expresses concern regarding the cost of prescription medications. The case manager can assist with identifying affordable medication options or connecting the client with financial assistance programs.
Client reports being unable to find transportation to follow-up appointment. The case manager can help arrange transportation or connect the client with community resources that can provide transportation assistance.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. While the provider may need to countersign the prescription, this does not affect the accuracy of the order at the time of receiving it.
B. Verifying the medication name along with its intended purpose helps ensure clarity and reduces the risk of medication errors, especially during telephone orders where miscommunication is more likely.
C. Verbalizing "B-I-D" rather than "twice per day" could cause confusion; clear language is essential, and "twice per day" is more understandable.
D. Using the generic name rather than the trade name is recommended to avoid confusion with similar brand names.

A. Provide postmortem care for a client who died 1 hr ago. B. Reinforce discharge instructions with a client who is 2 days postoperative following an appendectomy. C. Interpret deviations in a client's vital signs. D. Insert an NG tube for a client who has difficulty eating.

Correct Answer is A

Explanation

A. Providing postmortem care is a task that can be delegated to assistive personnel, as it involves following established protocols and does not require clinical judgment.
B. Reinforcing discharge instructions requires clinical knowledge and assessment, making it inappropriate for delegation to an AP.
C. Interpreting deviations in a client's vital signs necessitates nursing judgment and clinical expertise, which an AP does not possess.
D. Inserting an NG tube is a skilled nursing procedure that requires assessment and decision-making, thus it should not be delegated to an AP.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider, which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?

Correct Answer is A

Explanation

A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

A nurse is contributing to a quality improvement plan to improve the shift reporting process on the unit. Which of the following actions is the first step the nurse should suggest to promote a change in the reporting process?

A nurse is observing an assistive personnel (AP) provide care to a group of clients. Which of the following actions by the AP requires intervention by the nurse?

A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

A nurse enters a client's room and sees smoke coming from a wall outlet. After removing the client from the room, which of the following actions should the nurse take next?

A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?