A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?

A client who is receiving a blood transfusion and reports low-back pain

A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x105/uL (4.2 to 5.4 x106/uL)

A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing

A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag

Answer and Explanation

The Correct Answer is A

Rationale:
A. A client who is receiving a blood transfusion and reports low-back pain: Low-back pain during a blood transfusion indicates a possible acute hemolytic reaction caused by ABO incompatibility. This is a life-threatening emergency that requires immediate discontinuation of the transfusion and notifying the provider to prevent renal failure and shock.

B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x10⁶/µL (4.2–5.4 x10⁶/µL): Although the RBC count is slightly low, this finding is not immediately life-threatening. The provider should be informed, but the client does not require urgent intervention.

C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing: Small clots are expected during the first 24 to 36 hours post-TURP due to residual bleeding from the surgical site.

D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag: Small amounts of bloody mucus are normal during the early postoperative phase as the bowel mucosa heals.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Tends to be very expressive with gestures and body language: Chinese cultural norms often value modesty and restrained expression rather than overt gestures. Expecting expressive behavior may not align with typical postpartum practices.

B. Prefers to make direct eye contact with health care personnel: In many Chinese cultural contexts, avoiding direct eye contact is a sign of respect, especially toward authority figures, rather than a preference for direct engagement.

C. Prefers foods that maintain a balance of hot and cold within the body: Traditional Chinese postpartum practices emphasize restoring balance through diet, often using “hot” and “cold” foods to support recovery and prevent illness, making this a key consideration in care planning.

D. Expresses pain freely and loudly: Cultural norms often encourage quiet endurance of pain, especially postpartum, rather than vocal or exaggerated expressions of discomfort.

A. Obtaining the initial assessment of assigned clients B. Educating a client and family members on home care C. Changing a nonsterile dressing D. Interpreting a client's diagnostic laboratory results

Correct Answer is C

Explanation

Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.

B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.

C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.

D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is Chinese American and reports adhering to Chinese cultural postpartum practices. Which of the following should the nurse anticipate?

Correct Answer is C

Explanation

A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Correct Answer is C

Explanation

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

A nursery nurse is attending the birth of a post-term infant. Exhibits Upon review of the medical record, the infant newborn is at risk for developing which of the following symptoms? Select all that apply

A nurse is assisting a client who lives in a rural community with obtaining health services. Which of the following actions by the nurse demonstrates coordination of care?

A hospice nurse is performing a home visit for a client who is being cared for by their partner. Which of the following statements made by the partner indicates the partner is experiencing denial?

A nurse is providing teaching to a client who has a new prescription for nifedipine. Which of the following statements should the nurse include?

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take?

A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)