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 C

Explanation

The correct answer is choice C. The nurse does not cause any harm to the client.

Choice A rationale:

While having a license to practice nursing in the state where the event occurred is important for professional practice, it is not a specific requirement for the Good Samaritan law to provide civil immunity.The Good Samaritan law generally protects individuals who provide emergency care in good faith, regardless of their licensure status in that particular state.

Choice B rationale:

Basic life support (BLS) certification is a valuable credential for performing CPR and other emergency procedures. However, the Good Samaritan law does not require the responder to have BLS certification to be protected.The law focuses more on the intent and actions of the responder rather than their specific certifications.

Choice C rationale:

The primary criterion for the Good Samaritan law to provide civil immunity is that the responder does not cause harm to the client.The law is designed to protect those who act in good faith to provide emergency care without gross negligence or willful misconduct. If the nurse’s actions are reasonable and do not result in harm, they are typically protected under the Good Samaritan law.

Choice D rationale:

Remaining with the client when traveling to the hospital in an ambulance is not a requirement for Good Samaritan law protection. The law applies to the immediate emergency care provided at the scene.Once professional medical personnel take over, the Good Samaritan law’s protection generally ends.

A. A client who wants a bath. B. A client who asks to review the instructions he received about his new prescription. C. A client who needs a referral for home health services. D. A client who requests pain medication.

Correct Answer is D

Explanation

The nurse should prioritize the client who requests pain medication as their need is likely the most urgent. Pain management is an important aspect of nursing care and addressing the client's pain should be a priority.

The other clients have needs that are important but not as urgent as the client in pain. The client who wants a bath can wait until the nurse has addressed more pressing needs. The client who asks to review instructions about their new prescription can also wait, as long as they are not in immediate danger. The client who needs a referral for home health services can also wait until the nurse has addressed more urgent needs.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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