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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Valerian root: Valerian root is primarily used for its sedative properties and is commonly recommended for sleep disorders or anxiety. It does not have evidence-based benefits for lowering cholesterol levels and is not appropriate for this client's condition.
B. Garlic: Garlic has been shown in some studies to modestly reduce total cholesterol and low-density lipoprotein (LDL) levels. It may also have antiplatelet effects, making it a relevant herbal supplement for clients with elevated cholesterol when used appropriately.
C. Aloe: Aloe is typically used topically for wound healing or orally for constipation. It is not known to have any significant effect on lipid levels and is not recommended for cholesterol management.
D. Saw palmetto: Saw palmetto is most commonly used for benign prostatic hyperplasia (BPH) symptoms in men. It has no known lipid-lowering effects and is not suitable for managing high cholesterol.
Correct Answer is B
Explanation
Rationale:
A. "I will irrigate the colostomy every day.": Colostomy irrigation is used for descending or sigmoid colostomies to regulate bowel movements. It is not recommended for ascending colostomies because the stool is too liquid and unpredictable for effective irrigation.
B. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should be pink or red and moist. A purple or dusky appearance suggests compromised blood flow or ischemia and should be reported to the provider immediately as it may indicate a serious complication.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is generally liquid to semi-liquid due to the location in the digestive tract. Formed stool is more typical of descending or sigmoid colostomies, not ascending ones.
D. "I will no longer be able to eat nuts.": While some clients may choose to avoid certain foods based on personal tolerance, there is no absolute dietary restriction against nuts for colostomy clients unless otherwise advised.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.