A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?
A client who is 4 days postpartum and has mastitis
A client who had a bilateral tubal ligation 12 hr previously
A client admitted 1 hr ago for an ectopic pregnancy
A client who is a 1 day postpartum after a late term miscarriage
The Correct Answer is C
Rationale:
A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.
B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.
C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.
D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.
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Related Questions
Correct Answer is B
Explanation
Rationale:
A. Applying restraints to prevent an alert, oriented client from leaving AMA: This is an example of false imprisonment, not negligence.
B. Negligence is the failure to act as a reasonably prudent nurse would under similar circumstances. Notifying the provider hours after discovering absent peripheral pulses shows a delay in appropriate action, which can lead to serious complications (e.g., compartment syndrome, tissue ischemia). This failure to act promptly meets the definition of negligence.
C. Administering medication without the client’s knowledge after refusal: This constitutes battery, as it involves intentional, unauthorized physical contact.
D. Threatening to apply restraints if the client continues eating chips: This is assault, since it is a threat of harm without physical contact.
Correct Answer is B
Explanation
Rationale:
A. The National Council of State Boards of Nursing Decision Tree provides guidance for decision-making but does not specifically address delegation.
B. The state Nurse Practice Act defines the scope of practice for RNs and LPNs and is essential for understanding what tasks can be delegated.
C. The Omnibus Budget Reconciliation Act of 1987 primarily pertains to nursing home regulations and does not directly address task delegation.
D. The National Association for Practical Nurse Education and Services focuses on LPN education and standards, but the state Nurse Practice Act is more directly relevant to delegation.
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