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. Clients will have a decreased incidence of foot amputations is a measurable outcome goal for a diabetes management program and aligns with long-term objectives of improving patient outcomes.

B. A facility will be reserved for the program is a logistical consideration but not a goal of the program itself.

C. Handouts and teaching materials will be distributed at the program is a part of the program's implementation, not a goal.

D. Proper foot care will be demonstrated to clients during the program is a teaching activity, not a program outcome goal.

A. The name of the provider who prescribed the medication B. The time the client was to receive the medication C. The date of the Incident D. The client's vital signs E. The potential adverse effects of the medication

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

Explanation

Rationale:

A. The name of the provider who prescribed the medication is not necessary for the variance report; focus should be on the incident itself.

B. The time the client was to receive the medication should be included to document the discrepancy accurately.

C. The date of the incident is essential for accurate record-keeping and follow-up.

D. The client's vital signssuch as blood pressure are especially relevant for medications like furosemide, which affects fluid balance and blood pressure. These values help assess for harm or trends following the missed dose.

E. The potential adverse effects of the medication are not typically included in the incident report but might be noted in the client's ongoing care plan.

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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 planning a community diabetes mellitus management program. Which of the following goals should the nurse include for the program?

Correct Answer is A

Explanation

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)

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

Explanation

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?

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A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?

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A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents?