The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
A client who had an abdominal-perineal resection 3 days ago has no drainage on the dressing and is reporting chills.
A client who fell from a ladder and has a collapsed left lower lung with 100 mL drainage in a chest tube collection container.
A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm-sized dark red drainage.
A client who is post-mastectomy 2 days ago and has 50 mL of serosanguineous fluid in a Jackson-Pratt drain.
The Correct Answer is A
Choice A reason: This client may have an infection or sepsis, which are life-threatening complications of surgery. The nurse should assess the client's vital signs, wound appearance, and laboratory results, and notify the physician immediately.
Choice B reason: This client has a chest tube to drain the pleural fluid and re-expand the lung. The amount of drainage is within normal limits and does not indicate an emergency. The nurse should monitor the client's respiratory status, oxygen saturation, and chest tube function.
Choice C reason: This client has a gunshot wound that may have caused tissue damage and bleeding. The dressing with 2 cm-sized dark red drainage may indicate fresh bleeding, but it is not excessive. The nurse should check the dressing for signs of infection, change it as ordered, and report any changes to the physician.
Choice D reason: This client has a Jackson-Pratt drain to collect the fluid from the surgical site after a mastectomy. The amount of serosanguineous fluid is expected and does not indicate a problem. The nurse should empty and measure the drain output, record it, and report any abnormalities to the physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This client has a potential airway obstruction and needs close monitoring by the nurse. Laryngeal nerve damage can cause vocal cord paralysis, which can lead to respiratory distress and aspiration.
Choice B Reason: This client needs education on the medication and its side effects, but this can be done by the PN under the supervision of the nurse. Levothyroxine is a synthetic thyroid hormone that replaces deficient hormones in hypothyroidism.
Choice C Reason: This client needs ongoing management of diabetes, but this can be done by the PN under the supervision of the nurse. Glycosylated Hgb (Hgb A1C) is a measure of the average blood glucose level over the past three months.
Choice D Reason: This client has a life-threatening condition that requires immediate treatment with corticosteroids, but this can be done by the PN under the supervision of the nurse. Addison's crisis is a severe form of adrenal insufficiency that causes hypotension, shock, and electrolyte imbalance.
Correct Answer is B
Explanation
Choice A Reason: Demonstrating how to complete an adverse occurrence or variance report is important, but not the most important objective. This report is a tool for quality improvement and risk management, but it does not prevent litigation by itself. The nurse should also communicate effectively with the client and/or their family, and document the incident and the actions taken.
Choice B Reason: Discussing how to handle complaints from clients and/or their families is the most important objective, as it can help prevent or resolve conflicts, and avoid escalation to legal action. The nurse should listen empathetically, acknowledge the client's feelings and concerns, apologize if appropriate, explain the situation and the plan of care, and involve the supervisor or other resources if needed.
Choice C Reason: Describing how to obtain legal services if needed is relevant, but not the most important objective.
This objective implies that litigation is inevitable or expected, which may create a negative or defensive attitude in the staff nurses. The nurse should focus on preventing litigation by providing safe and quality care and building trust and rapport with the clients and/or their families.
Choice D Reason: Maintaining personal malpractice insurance is advisable, but not the most important objective. This objective may protect the nurse's personal assets in case of a lawsuit, but it does not prevent litigation from occurring. The nurse should follow the standards of practice and the policies and procedures of the organization, and document accurately and thoroughly.
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