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
If a nurse manager notices that a nurse who has a history of being resistant to change is not delivering care according to a new policy, the appropriate action for the nurse manager to take is to encourage the nurse to verbalize the reasons for their resistance to the change. This will allow the nurse manager to understand the nurse's concerns and work with them to address any issues and facilitate their acceptance of the new policy.
Option B is incorrect because ignoring the resistance and allowing peer pressure to facilitate a change in the nurse's behavior is not an effective or respectful way to address the issue.
Option C is incorrect because explaining the importance and rationale of implementing the new policy to the nurse may be necessary, but it should not be the first action taken.
Option D is incorrect because indicating that there will be disciplinary consequences if the nurse does not implement the new policy may be necessary, but it should not be the first action taken.
Correct Answer is D
Explanation
If a staff nurse suspects that a newly licensed nurse is chemically impaired, the staff nurse should notify the charge nurse of the situation. The charge nurse can then take appropriate action to address the situation and ensure patient safety.
Option A may be necessary at some point, but it should not be the first response.
Option B may also be necessary at some point, but it does not address the underlying issue.
Option C may not be appropriate as it may not be within the staff nurse's scope of practice to confront the newly licensed nurse regarding her behavior.
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