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 strict measurement of intake and output.

The client develops a postoperative fever.

The client is experiencing a therapeutic effect from their treatment

The client needs routine wound care performed.

Answer and Explanation

The Correct Answer is B

Rationale:

A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.

C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.

D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.

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Correct Answer is ["A","B","C","G","H"]

Explanation

Rationale:
• Urinary stasis: Immobility slows bladder emptying and ureteral flow, increasing residual urine. This promotes bacterial growth and risk of urinary tract infection. MS clients with decreased mobility are especially vulnerable.

• Calcium resorption: Bone demineralization occurs during prolonged immobility. Without weight-bearing, calcium is released from bone into the bloodstream, raising serum calcium and weakening bones.

• Contractures: Lack of movement leads to shortening and stiffening of muscles and joints. Over time, joints lose flexibility, especially if the client remains curled in one position.

• Hypocalcemia: The client is more likely to develop hypercalcemia due to calcium resorption from bones. There's no evidence of low calcium symptoms like tetany or numbness.

• Hypertension: The client's vital signs are within normal range. Immobility may reduce cardiac output over time, but it does not typically cause high blood pressure.

• Diarrhea: Immobility usually causes constipation due to slowed peristalsis. There's no report of active GI symptoms or triggers for diarrhea in this case.

• Pressure ulcer: Continuous pressure on one area reduces capillary blood flow. This leads to tissue ischemia and skin breakdown, especially over bony prominences like the hip and shoulder.

• Atelectasis: Lying on one side restricts lung expansion, and refusal to change positions impairs ventilation. This can cause alveolar collapse and decreased oxygen exchange.

A. Positions the client in a chair before applying the stockings B. Elevates the legs before applying the stockings C. Rolls the extra stocking material down to the client's knee D. Massages the legs before applying the stockings

Correct Answer is B

Explanation

Rationale:

A. Positions the client in a chair before applying the stockings: Applying antiembolic stockings while the client is in a seated position may lead to venous pooling in the lower extremities. This reduces the effectiveness of the stockings and may cause improper fit or increased pressure in dependent areas.

B. Elevates the legs before applying the stockings: Elevating the legs allows venous blood to drain from the lower extremities, reducing swelling and promoting proper application of the stockings. This ensures the stockings provide even compression and help prevent complications like thrombus formation.

C. Rolls the extra stocking material down to the client's knee: Rolling down the stockings creates a tourniquet effect, which can impair circulation and increase the risk of complications like venous stasis or skin breakdown. Stockings should be smooth and free of folds.

D. Massages the legs before applying the stockings: Massaging the legs, especially in a client with phlebitis, may dislodge a clot if present and increase the risk of embolism. Gentle handling without vigorous massage is essential in clients at risk for thromboembolic events.

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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 home care nurse is assisting with the care of a client. Exhibits The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.

Correct Answer is ["A","B","C","G","H"]

Explanation

A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

Correct Answer is B

Explanation

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