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 B
Explanation
Nonmaleficence is the ethical principle of doing no harm. It requires healthcare providers to avoid causing harm to their patients and to take steps to prevent harm from occurring.
The other options are also important ethical principles in healthcare, but they do not specifically refer to doing no harm. Justice [a] refers to the fair distribution of benefits and burdens in society. Beneficence [c] refers to the obligation to do good and promote the well-being of others. Veracity [d] refers to the obligation, to tell the truth and not deceive others.
Correct Answer is ["A","B","C","E"]
Explanation
SBAR stands for Situation, Background, Assessment, and Recommendation. It is a systematic method of communication that provides a structured framework for conveying important information about a patient. To ensure that the report is thorough, the nurse needs to include information about the situation of the patient, the background leading up to the situation, an assessment of the patient, and recommendations for moving forward.
Option d is incorrect because barriers to providing treatment are not part of the SBAR framework.
Option f is incorrect because the reason why the report is needed is not part of the SBAR framework.
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