The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?
An 82-year-old client with Alzheimer's disease and a newly fractured femur who has an indwelling urinary catheter and soft wrist restraints applied.
A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race.
A 34-year-old admitted today after an emergency appendectomy who has a PIV and indwelling urinary catheter.
A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline lock PIV.
The Correct Answer is A
A. The combination of cognitive impairment, physical injury, and restraints poses a high risk for complications such as infection, skin breakdown, and falls. Close monitoring and nursing interventions are critical to ensure safety, comfort, and appropriate care in this patient.
B. While this client may need some care for the electrolyte imbalance and nausea, this situation is more stable compared to the elderly client with Alzheimer's. The RN's role here would focus on managing the electrolyte disturbance and providing symptom relief.
C. Although this client is postoperative and may need some care, the RN's focus would primarily be on pain management and monitoring for infection or complications. However, the client’s condition is relatively stable compared to the elderly client with multiple risks.
D. This client is also stable and may require some ongoing monitoring for respiratory issues. However, the level of care needed is less intensive compared to a client with cognitive issues, restraints, and a recent fracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","G","H"]
Explanation
A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.
B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.
C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.
D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.
E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.
F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.
G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.
H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.
Correct Answer is A
Explanation
A. "Only your son can decide to who the laboratory results can be shared with."
Since the client is 18 years old, he is legally an adult and has the right to confidentiality regarding his medical information. The nurse should inform the mother that the son must provide consent before sharing any test results with her.
B. "I can give you those results as soon as I get them back from the laboratory." The nurse cannot release the results to the mother without the client's consent, as he is an adult and his medical information is confidential.
C. "I need to wait for the results of other tests before I can share the information to you." The nurse’s ability to share the results with the mother is based on the client’s consent, not on waiting for other tests.
D. "Let us wait for the healthcare provider to come and share this information with you." While it may be helpful for the healthcare provider to discuss the results, the key issue here is the client's consent. The nurse should clarify that the client is the one who must authorize sharing the results.
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