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
The State Board of Nursing is responsible for regulating the practice of nursing within a specific state. It establishes the scope of practice for LPNs and sets the standards for their education, licensure, and practice. Therefore, the State Board of Nursing would be the best source of information regarding the roles of an LPN in a med-surg setting.
The other options may provide some information about the roles of an LPN in a med-surg setting, but they are not the primary source. The facility Human Resources Department [a] may have information about job descriptions and responsibilities specific to that facility. Nursing textbooks [c] may provide general information about the roles of LPNs. Coworkers on your unit [d] may have personal experience and knowledge about the roles of LPNs in that specific unit, but their information may not be comprehensive or up-to-date.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today