The RN is serving as preceptor to a new graduate nurse who has recently passed the RN licensure (NCLEX®) examination. The new nurse has only been on the unit for 2 days. Which patient should be assigned to the new graduate nurse?
A 60-year-old patient with diabetes who has cellulitis of the left ankle.
A 50-year-old patient with diabetes just returned from the post-anesthesia care unit after a below-knee amputation.
A 72-year-old patient with diabetes with diabetic ketoacidosis who is receiving IV insulin.
A 70-year-old patient with diabetes who is showing signs of hyperglycemia.
The Correct Answer is A
Choice A rationale: Cellulitis management typically involves wound care, antibiotics, and monitoring. It's a suitable assignment for a new graduate nurse to begin learning about wound management and diabetic care.
Choice B rationale: Post-operative care for an amputation requires experience in assessing and managing post-surgical complications, which might not be suitable for a new graduate nurse.
Choice C rationale: Diabetic ketoacidosis management involves complex insulin therapy and critical care, which might be overwhelming for a new graduate nurse.
Choice D rationale: While hyperglycemia requires monitoring and intervention, the cause and severity need to be determined before assigning this patient to a new
graduate nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Post-surgery, there's a risk of lymphedema in the affected arm, so avoiding procedures like venipuncture or blood pressure measurements in the left arm helps prevent complications.
Choice B rationale: Obtaining a permanent breast prosthesis is a consideration post- recovery but not an immediate priority upon return to the surgical unit.
Choice C rationale: Patient-controlled analgesia instructions are important but don't specifically address immediate care after mastectomy.
Choice D rationale: Insisting that the patient examine the surgical incision might not be appropriate upon return to the unit, and it's typically done by healthcare professionals during dressing changes.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.
Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.
Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.
Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.
Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.
Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.
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