A nurse is receiving a change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg.

A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10.

A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 ml/hr

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.

Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.

Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.

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Correct Answer is D

Explanation

If a nurse overhears two assistive personnel (AP) discussing a client who is currently hospitalized in the hospital cafeteria, the appropriate action for the nurse to take is to quietly tell the APs that the conversation is inappropriate. This will allow the nurse to address the issue in a respectful and professional manner and remind the APs of their responsibility to maintain client confidentiality.
Option A is incorrect because completing an incident report may be necessary, but it should not be the first action taken.
Option B is incorrect because reporting the incident to the provider is not an appropriate action in this situation.
Option C is incorrect because documenting the occurrence in the client's medical record is not an appropriate action in this situation.

A. Organ donation. B. Disclosure of personal health care information. C. Durable Power of attorney for health care. D. Enteral feeding tubes.

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

Explanation

When reinforcing teaching with a client about advance directives, the nurse should include topics such as organ donation [a], disclosure of personal health care information [b], durable power of attorney for health care [c], and cardiopulmonary resuscitation [e]. Advance directives are legal documents that allow individuals to communicate their wishes about medical treatment and end-of-life care in the event that they are unable to make decisions for themselves. These topics are all important components of advance directives and should be discussed with the client.

Enteral feeding tubes [d] are not a topic that is typically included in discussions about advance directives. While enteral feeding may be a component of end-of-life care, it is not a specific topic that is addressed in advance directives.

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A nurse is receiving a change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters the hospital cafeteria for lunch and overhears two assistive personnel (AP) discussing a client who is currently hospitalized. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client about advance directives. Which of the following topics should the nurse include? (Select all that apply.)

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

Explanation

A nurse observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse take?

A nurse is assigning tasks for the upcoming shift. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

A charge nurse overhears a provider speaking to a staﬀ nurse in anger concerning incorrect supplies that are available. Which of the following actions by the charge nurse displays conﬂict resolution?

A nurse tells another nurse that she thinks that he did not provide adequate care for a client who underwent a hip arthroplasty earlier that day. Which of the following responses by the accused nurse demonstrates assertiveness?

Nurses are responsible not only for their actions but also for the actions of the staﬀ to whom they delegate work, including accurate documentation. What is the principle associated with this responsibility?

A ﬂoat nurse is given a client assignment that requires the use of unfamiliar skills and techniques. Which of the following actions should the nurse take?

A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?

A nurse enters a client's room and finds the client on the ﬂoor. Which of the following actions should the nurse take first?