A nurse working in a long-term care facility is assigned to care for four clients following the 0700 morning change-of-shift report. Which of the following clients should the nurse attend to first?
A client who has bronchitis, began receiving antibiotics yesterday and has a temperature of 38.3°C (101°F).
A client who has COPD and has an oxygen saturation of 90%.
A client who has Alzheimer's and was restless during the night.
A client who has diabetes and had a 0600 blood glucose level of 60 mg/dL.
The Correct Answer is D
Of the four clients described, the nurse should attend to the client who has diabetes and had a 0600 blood glucose level of 60 mg/dL first. This client's blood glucose level is low and requires immediate intervention to prevent further complications.
Option A may require attention, but the client's condition is stable and they are receiving treatment.
Option B may also require attention, but an oxygen saturation of 90% is within an acceptable range for a client with COPD.
Option C may also require attention, but the client's restlessness during the night does not indicate an immediate need for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When resolving a conflict with an assistive personnel (AP) who refuses a client assignment, it would be appropriate for the nurse to say "I need to talk to you about the unit policies regarding client assignments." This comment addresses the issue directly and professionally and provides an opportunity for the nurse to clarify the unit policies and expectations.
Option A is accusatory and unprofessional.
Option B may be necessary at some point, but it should not be the first response.
Option C is also accusatory and unprofessional.
Correct Answer is D
Explanation
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as recording vital signs ¹. Obtaining vital signs on clients who are stable [d] is a task that can be delegated to an AP.
The other options are not tasks that should be delegated to an AP. Assisting the client to select a low-residue diet [a] and reviewing the steps of self-blood glucose monitoring with a client [c] involves patient education and dietary planning, which are typically the responsibility of a licensed nurse. Performing a complex dressing change [b] is a complex task that requires specialized knowledge and skills.
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