A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

"The client works in the hospital radiology department."

"The client discussed having prior thoughts of suicide."

"The client's blood pressure and pulse have been fluctuating throughout the day."

"The client's family members have been present most of the day."

Answer and Explanation

The Correct Answer is C

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

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Correct Answer is B

Explanation

Rationale:

A. Reinforcing discharge teaching is less critical during a disaster and should be secondary to addressing immediate needs.

B. Focusing on life-threatening emergencies aligns with the priorities in a disaster situation, where resources are limited.

C. Stocking additional supplies should be managed based on current needs and priorities but is not as urgent as immediate patient care.

D. Focusing on ADLs is important but not the priority when dealing with life-threatening situations.

A. The client is inappropriate and is a huge fall risk B. The provider has denied this RN's requests for physical or chemical restraints C. They appear 'medically stable D. The partner is at bedside and said that their spouse is always complaining or arguing E. the ICU and progressive care unit are full F. the client is being admitted to this medical unit G. Denies pain. Sitting up in bed

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

Explanation

The nurse's documentation of the client being "inappropriate" is vague and unprofessional. Additionally, using the term "huge fall risk" without a specific assessment or plan to mitigate the risk (e.g., implementing fall precautions) is not adequate documentation. Further, the nurse’s reliance on physical or chemical restraints without exploring alternative interventions suggests a need for education on restraint use and patient safety practices.

The nurse's notes reflect a subjective description of the client's behavior as 'inappropriate' and 'complaining or arguing,' which is not objective or professional. It is important for nursing documentation to remain objective and to describe observed behaviors rather than labeling them. The statement that the client is "medically stable" should be supported by objective data rather than subjective observation, and it is important to note that mental health stability is also a crucial aspect of overall health.

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A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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

Explanation

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