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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the client's provider: Notifying the provider is important if there is concern for injury, but this should follow the initial assessment to determine the client’s condition. Immediate evaluation takes priority to identify any life-threatening or urgent issues.
B. Measure the client's vital signs: Assessing vital signs is the first action because it provides critical information about the client’s hemodynamic status and identifies potential injuries or complications, such as internal bleeding or shock, following the fall. This guides subsequent interventions and provider notification.
C. Complete an incident report: Completing an incident report is necessary for legal and quality improvement purposes, but it is not the first priority. The client’s safety and clinical assessment take precedence over documentation.
D. Document the fall in the client's medical record: Accurate documentation is essential for continuity of care and legal reasons, but it should occur after assessing the client’s condition and initiating any necessary interventions.
Correct Answer is A
Explanation
A. “I should practice pursed-lip breathing exercises.": This technique involves inhaling through the nose and exhaling slowly through pursed lips (as if whistling). This creates back-pressure in the airways, which keeps the bronchioles open longer during exhalation. This helps the client remove trapped carbon dioxide (CO2), reduces shortness of breath, and promotes relaxation.
B. "I will consume low-protein, low-calorie foods": Clients with COPD require adequate protein and calories to maintain muscle mass and energy for breathing. Restricting protein and calories could worsen muscle wasting and fatigue.
C. “I should do aerobic exercises once per day": While regular physical activity is beneficial, exercise should be paced and tailored to the client’s tolerance. Overexertion can exacerbate dyspnea and fatigue in COPD clients.
D. "I will increase my fluid intake to 1,700 milliliters per day.": While hydration is important to thin secretions, 1,700 mL is on the lower end of standard daily requirements for an adult. Clients with COPD are encouraged to drink 2 to 3 liters (2,000 to 3,000 mL) of fluid per day (unless contraindicated by heart failure) to help liquefy thick mucus, making it easier to cough up.
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