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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Dorsal recumbent: Lying flat on the back does not optimize airway protection or reduce strain on the surgical site after a thyroidectomy. This position may increase discomfort and risk of edema.

B. Semi Fowler's: Elevating the head of the bed to a semi-Fowler’s position helps reduce neck swelling, promotes airway patency, and decreases tension on the suture line. It also facilitates easier breathing and comfort during the postoperative period.

C. Left lateral: Side-lying positions are not indicated after a thyroidectomy unless the client has specific complications. They do not provide the same benefits for airway management and suture care as semi-Fowler’s.

D. Supine: Lying completely flat can increase neck edema and discomfort post-thyroidectomy. Maintaining a semi-Fowler’s position is preferred to support recovery and airway safety.

A. Respiratory rate B. Oxygen saturation level C. Chronic health condition D. Tremors E. Current level of consciousness F. Heart rate

Correct Answer is ["A","B","E"]

Explanation

A. Respiratory rate: A respiratory rate of 30 breaths per minute indicates significant respiratory distress. Labored breathing combined with crackles and wheezes suggests impaired gas exchange and possible lower respiratory infection requiring urgent intervention.

B. Oxygen saturation level: An oxygen saturation of 89% on room air reflects hypoxemia. Reduced oxygen levels place the client at risk for tissue hypoxia and worsening respiratory failure, making prompt follow-up and oxygen therapy necessary.

C. Chronic health condition: A history of smoking, Parkinson’s disease, and anxiety increases overall health risk but does not explain the acute deterioration. Chronic conditions provide context but are not the immediate priority compared with current unstable findings.

D. Tremors: Hand tremors are consistent with Parkinson’s disease and may also be worsened by anxiety or illness. Tremors alone do not pose an immediate life-threatening risk in this situation.

E. Current level of consciousness: Orientation only to self and failure to follow commands suggest acute changes in mental status. Altered cognition in an older adult with fever and hypoxia may indicate delirium or worsening infection and requires immediate evaluation.

F. Heart rate: A heart rate of 104 beats per minute indicates mild tachycardia, likely related to fever or hypoxia. Although important to monitor, it is less immediately threatening than hypoxemia, tachypnea, and altered mental status.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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