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. The nurse disagrees with the nurse manager about inadequate staffing. B. A staﬀ member has not arrived at the facility to work an assigned shift. C. A client tells the nurse that his dentures are missing. D. The nurse discovers that the client does not have advanced directives.

Correct Answer is C

Explanation

An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone— patient, staﬀ member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required ⁴. In this case, the client's missing dentures would be considered a complaint and would require the nurse to complete an incident report.

The other options do not require an incident report. Disagreeing with the nurse manager about inadequate staffing [a], a staﬀ member not arriving at the facility to work an assigned shift [b], and discovering that the client does not have advanced directives [d] are not situations that would require an incident report according to the information provided in my sources.

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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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