A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

"The client who had abdominal surgery 3 days ago is reporting feeling constipated.”

"The client who had the hip replacement reports pain as 4 on a scale of 0 to 10.”

"The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.”

"The client who is scheduled for discharge today states they are ready to sign their paperwork.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.

Choice B rationale:

The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.

Choice C rationale:

The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.

Choice D rationale:

The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.

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Correct Answer is B

Explanation

The correct answer is choice B: "This is a procedure that does not require written informed consent."

Choice B rationale: Informed consent is typically required for invasive procedures, surgery, or treatments that carry significant risks. While inserting an indwelling urinary catheter is considered an invasive procedure, it is generally not a procedure that requires written informed consent. Nurses often have standing orders or standardized procedures in place for catheterization, and consent is usually implied or obtained verbally.

Choice A rationale: Although providers prescribe procedures, consent is still necessary in many cases. However, as mentioned above, written informed consent is not typically required for urinary catheter insertion due to its routine nature in medical care.

Choice C rationale: Discussing the issue with the charge nurse is unnecessary since written informed consent is not generally required for this procedure. The nurse should instead focus on educating the family about standard hospital practices.

Choice D rationale: Asking the family to sign the informed consent form at this point is not appropriate, as it implies that the procedure should not have been performed without written consent. Additionally, urinary catheterization does not typically require written informed consent, so asking them to sign a form could create confusion or unnecessary concern.

A. The child has red fissures at the corners of the mouth. B. The child has several small bruises on both legs. C. The child sleeps for about 13 hours each night. D. The child is not regularly attending school.

Correct Answer is B

Explanation

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

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A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

Correct Answer is B

Explanation

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