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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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. When opening a sterile package or tray, the top flap should be opened away from the body to prevent contamination from the nurse’s uniform. Opening the flap toward the body risks breaking sterile technique, which is especially critical during procedures like thoracentesis. This is a break in sterile field, and the nurse manager should intervene immediately to prevent potential infection.

B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.

C.The telephone number is considered an acceptable identifier according to The Joint Commission if it is in the medical record and used in combination with another identifier (like full name or date of birth).

D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.

A. The physiologic status of the clients on the unit B. Social relationships between nurses working the oncoming shift C. Personal comfort level in making the assignments D. The most experienced nurse receives the more complex clients

Correct Answer is A

Explanation

Rationale:

A. The physiologic status of the clients is the most critical factor in assigning tasks, ensuring that clients with more complex needs receive appropriate care.

B. Social relationships are secondary to patient safety and quality of care.

C. Personal comfort level should not influence assignment decisions; patient care needs are the priority.

D. Assigning the most experienced nurse to complex clients is appropriate, but it should be based on client needs rather than just experience alone.

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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 manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?

Correct Answer is A

Explanation

A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?

Correct Answer is A

Explanation

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