When a nurse responds to a client's call light, the client tells the nurse that his watch is missing.

He states that he left it in the drawer of his bedside table, and now it is not there.

Later, the nurse sees an assistive personnel (AP) taking a man's watch from her pocket and putting it in her purse.

Which of the following actions should the nurse take?

Report the observation to the immediate supervisor.

Confront the AP about her theft of the client's watch.

Tell the client that the AP took his watch.

Call security before the AP leaves the building.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Reporting the observation to the immediate supervisor is the most appropriate and ethical action. The nurse is a mandated reporter for such events within the healthcare setting. The supervisor, in their administrative role, is responsible for initiating a formal investigation into the matter, ensuring due process, and taking necessary disciplinary action according to institutional policy. This approach protects both the client and the nurse, who is acting on observed evidence, and maintains a chain of command.

Choice B rationale

Confronting the assistive personnel (AP) directly is an inappropriate and potentially unsafe action. This approach could escalate the situation, lead to a hostile confrontation, and create an unsafe work environment. The nurse's role is not to act as a law enforcement officer or to administer disciplinary action. The proper channel for addressing a suspected theft is through the established reporting structure, which involves informing the immediate supervisor. This maintains professional boundaries and ensures a fair and impartial investigation.

Choice C rationale

Telling the client that the assistive personnel (AP) took their watch is premature and unprofessional. The nurse has only observed the AP with a watch, but has not yet confirmed it is the client's. Making such an accusation directly to the client could be slanderous, cause emotional distress, and is not a factual statement. The proper procedure is to report the observation to the supervisor and allow the official investigation to proceed, which will determine the facts before any conclusions are drawn or communicated.

Choice D rationale

Calling security before the assistive personnel (AP) leaves the building is an excessive and premature action. The nurse's role is to report concerns to the immediate supervisor, who will then follow the proper institutional procedures, which may include contacting security if deemed necessary. Bypassing the chain of command and taking unilateral action could create a chaotic and unmanaged situation, potentially infringing on the AP's rights. The supervisor is the designated authority to manage such incidents and coordinate with other departments as needed. *.

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Correct Answer is D

Explanation

Choice A rationale

Crusting along the incision line is the result of dried serous fluid and blood, which is a normal part of the wound healing process during the inflammatory phase. This finding alone is not indicative of a surgical site infection, which is characterized by other signs.

Choice B rationale

A temperature of $37.2^\circ C$ ($99^\circ F$) is within the normal range for body temperature ($36.1^\circ C$ to $37.2^\circ C$ or $97^\circ F$ to $99^\circ F$). An elevated temperature, specifically a fever, is a systemic sign of infection. A low-grade fever might be a subtle sign, but this temperature is not high enough.

Choice C rationale

Pink coloration of the incision line is a normal finding in the early stages of wound healing, representing angiogenesis, the formation of new blood vessels. This process is crucial for tissue repair and does not indicate a surgical site infection, which is typically characterized by erythema and warmth.

Choice D rationale

Swelling, or edema, is a classic sign of inflammation and infection. While some minor swelling is normal, swelling that extends significantly beyond the wound margins, such as 3.8 cm (1.5 in), indicates a heightened inflammatory response potentially due to bacterial proliferation and infection. *.

A. A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions. B. A 3-year-old child who has an atrial septal defect and a heart rate of 120/min. C. A 2-year-old child who has diarrhea and reports abdominal pain. D. A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL.

Correct Answer is A

Explanation

Choice A rationale

This 12-year-old child with cystic fibrosis and difficulty clearing secretions is the priority. Cystic fibrosis causes thick mucus to accumulate in the lungs, leading to airway obstruction. Inability to clear these secretions indicates a potential acute respiratory crisis, which can rapidly progress to respiratory failure. This is a life-threatening airway and breathing emergency requiring immediate assessment and intervention to prevent respiratory compromise.

Choice B rationale

A 3-year-old with an atrial septal defect and a heart rate of 120/min is a non-acute finding. A heart rate of 120/min is within the normal range for a toddler (90-140/min) and is a common physiological response in a child with a heart defect to maintain cardiac output. This child is stable and does not present with an immediate life-threatening condition.

Choice C rationale

A 2-year-old with diarrhea and abdominal pain is a non-acute finding. While these symptoms require attention, they are common in toddlers and do not typically represent an immediate life-threatening emergency unless accompanied by signs of severe dehydration or septic shock. Other children with respiratory issues take priority due to the higher potential for rapid decompensation.

Choice D rationale

A 5-year-old with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is stable. A blood sugar of 150 mg/dL is within a safe, controlled range for a child with type 1 diabetes, which is typically 80-180 mg/dL. This child does not require immediate intervention as their blood glucose is not indicative of hypo- or hyperglycemia crises. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is replacing the dressing for a client who is postoperative following thoracic surgery. When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?

Correct Answer is D

Explanation

A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

Correct Answer is A

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

A nurse is caring for a client who has schizophrenia. The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?

A nurse is assessing a client who is postpartum and has developed endometritis. Which of the following findings should the nurse expect?

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take.

A nurse is providing teaching to a guardian of a child who has ADHD. Which of the following strategies should the nurse suggest to improve the child's ability to concentrate?

A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?