The nurse receives 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 was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm sized dark red drainage.

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 is post-mastectomy 2 days ago and has 50 ml of serosanguineous fluid in a Jackson-Pratt drain.

A client who had an abdominal perineal resection 3 days ago and has no drainage on the dressing and is reporting chills.

Answer and Explanation

The Correct Answer is B

Choice A rationale: While the client with the gunshot wound requires attention, the client with a collapsed left lower lung and 100 ml drainage in a chest tube collection container is at immediate risk for respiratory compromise.

Choice B rationale: The client who fell from a ladder with a collapsed left lower lung and 100 ml drainage in a chest tube collection container requires the most immediate intervention to address potential respiratory distress.

Choice C rationale: The client post-mastectomy with 50 ml of serosanguineous fluid in a Jackson-Pratt drain may need attention, but the respiratory distress in the other client takes precedence.

Choice D rationale: The client who had an abdominal perineal resection with no drainage on the dressing and reporting chills may require attention, but the respiratory distress in the other client is a more urgent concern.

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Correct Answer is A

Explanation

Choice A rationale: The nurse can delegate urinary catheter irrigations to the PN, as this is a skill that can be performed by a licensed nurse under the supervision of a registered nurse (RN).

Choice B rationale: Initiating teaching for client care after discharge is within the scope of a registered nurse and may not be delegated to a practical nurse.

Choice C rationale: Beginning initial sterile wound care for surgical clients may fall under the scope of a registered nurse or other licensed staff, not necessarily a practical nurse.

Choice D rationale: Receiving a postoperative client and conducting the assessment also requires the RN's critical thinking and clinical skills.

A. Apply portable oxygen for transport to radiology. B. Administer a nebulizer breathing treatment. C. Evaluate breathing pattern. D. Start the prescribed antibiotic.

Correct Answer is B

Explanation

Choice A rationale: Applying portable oxygen for transport to radiology is not the first priority. The immediate concern is assessing and addressing the client's respiratory distress before initiating specific interventions.

Choice B rationale:The nebulizer treatment should be administered FIRST to alleviate the clients obstructed airway (respiratory distress)

Choice C rationale: Evaluating the breathing pattern is important but should be done immediately after implementing physician orders

Choice D rationale: Starting the prescribed antibiotic is not the first priority. Respiratory assessment takes precedence to address the client's immediate distress.

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The nurse receives 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

The nurse-manager overhears a nurse complaining to a co-worker about the time being required to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?

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