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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The principle associated with the responsibility of nurses for their actions and the actions of the staff to whom they delegate work, including accurate documentation, is accountability. This means that nurses are responsible for ensuring that the care provided by themselves and their staff meets the appropriate standards and that all documentation is accurate and complete.
Option B is incorrect because conflict resolution is a process for resolving disagreements or disputes.
Option C is incorrect because coordination of care refers to the process of organizing and managing a patient's healthcare needs.
Option D is incorrect because authoritativeness refers to the ability to make decisions and provide direction.
Correct Answer is B
Explanation
The first action the nurse should take is to speak with the other nurse privately. This allows the nurse to address the mistake in a respectful and professional manner and provide guidance on how to perform the procedure correctly in the future.
Option A is incorrect because correcting the mistake independently does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option C is incorrect because volunteering to perform the procedure next time does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option D is incorrect because submitting an incident report may be necessary, but it should not be the first action taken.
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