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A nurse is receiving change-of-shift report for a group of clients.
Which of the following clients should the nurse plan to assess first?

A.

A client who has epidural analgesia and weakness in the lower extremities.

B.

A client who has diabetes mellitus and an HbA1c of 6.89%.

C.

A client who has a hip fracture and a new onset of tachypnea.

D.

A client who has sinus arrhythmia and is receiving cardiac monitoring.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.

Choice B rationale:

The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.

Choice C rationale:

The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.

Choice D rationale:

The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.


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Related Questions

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

Explanation

Choice A rationale:

Making decisions about health care on clients' behalf without their involvement violates the principle of patient autonomy. Patients have the right to be actively involved in decisions about their own care and treatment plans. Encouraging shared decision-making and respecting patients' choices are essential aspects of nursing advocacy.

Choice B rationale:

Promoting health care access is a fundamental aspect of advocacy in client care. Nurses should advocate for their patients' access to necessary healthcare services, treatments, and resources. This includes ensuring that patients have access to appropriate medical facilities, specialists, medications, and therapies. Advocating for health care access helps patients receive timely and appropriate care, improving their overall health outcomes.

Choice C rationale:

Encouraging clients to seek further information from the provider is crucial for informed decision-making. Providing patients with accurate and relevant information enables them to make educated choices about their health. Nurses can facilitate this process by clarifying medical information, explaining treatment options, and addressing patients' concerns. Informed patients are better equipped to actively participate in their care and advocate for their own needs.

Choice D rationale:

Addressing client needs when providing resources is an essential aspect of nursing advocacy. Nurses should assess their patients' individual needs and collaborate with other healthcare professionals to provide appropriate resources and support. This can include coordinating social services, arranging for home healthcare, or connecting patients with support groups. Meeting clients' needs ensures that they receive comprehensive care, promoting their overall well-being.

Choice E rationale:

Honoring family requests to withhold medical information can be ethically challenging. While family members play a significant role in a patient's life, confidentiality and patient autonomy must be respected. In most cases, healthcare providers should prioritize communicating directly with the patient, respecting their right to make decisions about their own health information. Exceptions may arise in situations involving legal guardianship or when patients are unable to communicate their preferences. However, the default approach should be to involve the patient directly in decisions about their healthcare information.

Correct Answer is D,C,B,A

Explanation

In the event of a fire, the nurse should prioritize safety and follow the facility’s emergency protocols, which typically align with the “RACE” acronym: Rescue: d. Transport the client to another area of the nursing unit. Ensure the client is safe from immediate danger. Alarm: c. Activate the facility’s fire alarm system. Alert others in the facility by activating the fire alarm. Confine: b. Close all nearby windows and doors. Prevent the spread of fire by closing doors and windows. Extinguish: a. Use the unit’s fire extinguisher to attempt to put out the fire. If it’s safe to do so, attempt to extinguish the fire using a fire extinguisher. Remember, the safety of the client and the nurse is the top priority. If the fire is too large or the situation too dangerous, the nurse should evacuate and wait for the fire department to handle the situation. Always follow the specific procedures of your healthcare facility.

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