A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?
The client needs routine wound care performed.
The client develops a postoperative fever.
The client is experiencing a therapeutic effect from their treatment.
The client needs strict measurement of intake and output
The Correct Answer is B
A. The client needs routine wound care performed: Routine wound care is a stable, predictable task that can be delegated to assistive personnel. It does not require the judgment or assessment skills of a registered nurse.
B. The client develops a postoperative fever: A postoperative fever may indicate infection or another complication that requires assessment, clinical judgment, and possible intervention by a registered nurse. This warrants transfer of care to the RN for evaluation and appropriate action.
C. The client is experiencing a therapeutic effect from their treatment: Observing a therapeutic response is expected and does not necessitate RN-only care. Monitoring for ongoing effectiveness can be performed by other trained personnel as appropriate.
D. The client needs strict measurement of intake and output: While accurate intake and output monitoring is important, it is a routine, measurable task that can be delegated to assistive personnel. It does not require RN assessment unless abnormalities are noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for correct choices:
• N95 respirator: Mycobacterium tuberculosis is transmitted via airborne particles that remain suspended in the air. An N95 respirator is required to filter airborne droplet nuclei and protect the nurse from inhalation exposure. Standard surgical masks do not provide adequate airborne protection in confirmed TB cases.
• Gloves: As part of Standard Precautions, gloves should always be worn when there is a risk of contact with body fluids, such as sputum or contaminated surfaces in the client's room.
Rationale for incorrect choices:
• Surgical mask: A surgical mask protects against large respiratory droplets but does not filter airborne particles. TB requires airborne precautions, which exceed the level of protection provided by a standard mask. Surgical masks are more appropriate for droplet-based infections.
• Face shield: A face shield protects mucous membranes from splashes or sprays but does not filter inhaled air. TB does not spread via splashes, making this equipment unnecessary for routine airborne precautions. Respiratory protection remains the priority.
Correct Answer is ["A","D","E"]
Explanation
A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.
B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.
C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.
D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.
E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.
F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.
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