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 A

Explanation

The principle associated with the responsibility of nurses for their actions and the actions of the staﬀ to whom they delegate work, including accurate documentation, is accountability. This means that nurses are responsible for ensuring that the care provided by themselves and their staﬀ meets the appropriate standards and that all documentation is accurate and complete.
Option B is incorrect because conﬂict resolution is a process for resolving disagreements or disputes.
Option C is incorrect because coordination of care refers to the process of organizing and managing a patient's healthcare needs.
Option D is incorrect because authoritativeness refers to the ability to make decisions and provide direction.

A. The nurse has a license to practice nursing in the state where the event occurred. B. The nurse has basic life support certification. C. The nurse does not cause any harm to the client. D. The nurse remains with the client when traveling to the hospital in an ambulance.

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.

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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

Nurses are responsible not only for their actions but also for the actions of the staﬀ to whom they delegate work, including accurate documentation. What is the principle associated with this responsibility?

Correct Answer is A

Explanation

A nurse witnesses an adult who is experiencing a cardiac arrest while at the grocery store. The nurse performs CPR. Which of the following criteria is necessary for the Good Samaritan law to provide civil immunity for the nurse?

Correct Answer is C

Explanation

A charge nurse overhears a provider speaking to a staﬀ nurse in anger concerning incorrect supplies that are available. Which of the following actions by the charge nurse displays conﬂict resolution?

A nurse tells another nurse that she thinks that he did not provide adequate care for a client who underwent a hip arthroplasty earlier that day. Which of the following responses by the accused nurse demonstrates assertiveness?

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

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to see first?

Doing no harm is?

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:

A charge nurse in a long-term care facility reviews client outcomes when delegating tasks to assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the charge nurse include in the teaching?