A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?

Assessing a client who experiences unilateral calf pain when ambulating

Reassuring the partner of a client who sustained a closed head injury

Taking a telephone prescription about a client who is to be transferred from PACU

Reinforcing a client’s dressing for the surgical site of an above the knee amputation

Answer and Explanation

The Correct Answer is A

A. Assessing a client who experiences unilateral calf pain when ambulating.
Unilateral calf pain in a client who is ambulating can be indicative of a potential deep vein thrombosis (DVT), which is a serious condition that requires prompt assessment and intervention. DVTs are a risk after surgery, and early detection is crucial to prevent complications such as a pulmonary embolism. Assessing the client experiencing calf pain is the priority to determine the cause and initiate appropriate interventions.

B. Reassuring the partner of a client who sustained a closed head injury:
While providing support and reassurance to family members is important, it is not as urgent as assessing a client with potential signs of a DVT.

C. Taking a telephone prescription about a client who is to be transferred from PACU:
While obtaining and implementing orders in a timely manner is important, assessing and addressing a potential DVT takes precedence due to the immediate risk to the client's well-being.

D. Reinforcing a client’s dressing for the surgical site of an above-the-knee amputation:
Dressing reinforcement is important for wound care, but it is not as urgently needed as assessing a client with possible signs of a DVT. The assessment of calf pain takes priority.

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Correct Answer is A

Explanation

A. Suppress respiratory effort
Pancuronium is a neuromuscular blocking agent that is often used to induce paralysis in patients requiring mechanical ventilation. It works by blocking the transmission of nerve impulses at the neuromuscular junction, leading to skeletal muscle paralysis. In the context of a client with acute respiratory distress syndrome (ARDS) on mechanical ventilation, the use of pancuronium helps to suppress respiratory effort, allowing for better control of the patient's ventilation and oxygenation.

B. Decrease chest wall compliance:
Pancuronium does not directly affect chest wall compliance. It primarily acts on skeletal muscles, leading to paralysis.

C. Decrease respiratory secretions:
Pancuronium is not used to decrease respiratory secretions. It is a neuromuscular blocking agent with the main goal of inducing paralysis.

D. Induce sedation:
Pancuronium does not induce sedation. It works on the neuromuscular junction and does not have sedative properties. Sedation may be achieved with other medications, such as sedative agents.

A. Teaching a client insulin injection technique B. Evaluating changes to a client’s pressure ulcer C. Admission assessment of a new client D. Scheduling a diagnostic study for a client

Correct Answer is A

Explanation

A. Teaching a client insulin injection technique.
Licensed practical nurses (LPNs) are trained to provide direct patient care, including the administration of medications and patient education. Teaching a client insulin injection technique falls within the scope of practice for an LPN.

B. Evaluating changes to a client’s pressure ulcer:
Assessing and evaluating changes in a client's condition, including pressure ulcers, involves clinical judgment and interpretation of findings, tasks typically performed by an RN.

C. Admission assessment of a new client:
Conducting comprehensive assessments, especially for new admissions, requires a higher level of nursing assessment skills and is generally within the scope of practice for an RN.

D. Scheduling a diagnostic study for a client:
The task of scheduling diagnostic studies involves organizational and administrative skills. RNs often handle coordination of care, including scheduling, as part of their responsibilities.

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A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Correct Answer is A

Explanation

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

Correct Answer is A

Explanation

A patient is on the ventilator and a high-pressure alarm sounds. The nurse should assess for which of these possible causes for the alarm?

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A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

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A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?

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