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. Assessment of the patient. B. Recommendations for moving forward. C. Situation of the patient. D. Barriers to providing treatment. F. Reason why the report is needed.

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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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 wants to prepare a patient report utilizing SBAR, which she knows is a systematic method of communication. To ensure the report is thorough, what types of information does she need? SELECT ALL THAT APPLY

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

Explanation

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 is reinforcing teaching about delegation to assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

A charge nurse in an acute care facility receives a client's request not to have particular assistive personnel (AP) care for her. Which of the following actions should the charge nurse take?

A nurse is preparing to perform a urinary catheterization to obtain a urine specimen for a client. The client tells the nurse that she is concerned about her privacy during the procedure. Which of the following actions should the nurse take to alleviate the client's concern?

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

A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Doing no harm is?

A nurse is delegating client care assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to the assistive personnel (AP)?