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

Explanation

Rationale:

A. Consult with a pharmacist about the medication: Consulting a pharmacist is the most appropriate action when a nurse is unfamiliar with a medication. Pharmacists are knowledgeable about drug indications, dosages, side effects, and interactions, making them a key resource for medication safety.

B. Ask the client about the medication: Clients may have some knowledge about their prescriptions, but they are not reliable sources for professional clinical decisions. Relying on client input when the nurse lacks knowledge could lead to unsafe medication administration.

C. Ask the charge nurse to administer the medication: Delegating the task does not resolve the knowledge gap. The nurse remains responsible for ensuring they understand any medication they are preparing, and should take steps to educate themselves rather than pass the task to another nurse.

D. Complete an incident report: An incident report is only warranted if a medication error or adverse event occurs. Being unfamiliar with a drug and seeking clarification is a preventive measure, not an incident requiring formal reporting.

A. Polyuria B. Hypertension C. Constipation D. Bradycardia

Correct Answer is B

Explanation

Rationale:

A. Polyuria: Polyuria is not a typical symptom of alcohol withdrawal. Although chronic alcohol use may affect renal function, withdrawal is more commonly associated with symptoms of autonomic hyperactivity rather than increased urine output.

B. Hypertension: Hypertension is a common manifestation of alcohol withdrawal due to autonomic nervous system overactivity. As the central nervous system adapts to the absence of alcohol, clients may experience elevated blood pressure, tremors, and agitation.

C. Constipation: Constipation is not expected during alcohol withdrawal. Clients are more likely to experience diarrhea or gastrointestinal upset due to nervous system stimulation and stress responses.

D. Bradycardia: Bradycardia is not characteristic of alcohol withdrawal. Instead, clients often present with tachycardia and other signs of heightened sympathetic activity due to the sudden absence of CNS depressant effects.

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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

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Explanation

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Correct Answer is B

Explanation

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