Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.

A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.

A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.

An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can transport a stable postoperative client to another unit and report any changes or concerns to the primary nurse.

Choice B Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can monitor the blood pressure of a client with hypertension and administer antihypertensive medications as prescribed and delegated by the primary nurse.

Choice C Reason: This assignment does not require immediate follow-up action by the charge nurse because a graduate nurse can obtain a unit of packed red blood cells from the blood bank and verify the compatibility and identification with another registered nurse before transfusing it to the client.

Choice D Reason: This is the correct answer because checking a client for fecal impaction is beyond the scope of practice of unlicensed assistive personnel. It involves inserting a finger into the rectum and assessing for hard stool, which can cause injury or infection to the client. The charge nurse should intervene and assign this task to a registered nurse or a practical nurse.

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Correct Answer is D

Explanation

Choice A Reason: This is not the first priority because it does not address the client's immediate needs. The nurse should obtain the client's legal records for power of attorney, but this can be done later.

Choice B Reason: This is a good action because it helps relieve the client's pain and discomfort. The nurse should give analgesic medications as needed (PRN), but this is not enough to meet the client's holistic needs.

Choice C Reason: This is not an appropriate action because it may cause harm to the client. The nurse should not discontinue the intravenous infusion without a valid reason and a healthcare provider's order.

Choice D Reason: This is the best action because it respects the client's wishes and provides him with quality end-of-life care. The nurse should ask the palliative care team to speak with the client and offer him emotional, spiritual, and physical support.

A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L). B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5. C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L). D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).

Correct Answer is A

Explanation

Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.

Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.

Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that

increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.

Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.

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Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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