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An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?
- A. A client who has acute pancreatitis
- B. A client who is one-day postoperative following a total abdominal hysterectomy
- C. A client who had a stroke and is to be admitted
- D. A client who has terminal end-stage renal disease
Correct Answer: B
Rationale: The correct answer is B: A client who is one-day postoperative following a total abdominal hysterectomy. This assignment is appropriate because a nurse from the maternal-newborn unit would likely have experience with postoperative care, wound care, pain management, and monitoring for complications such as hemorrhage or infection. The nurse would also be knowledgeable about assessing vital signs, managing surgical drains, and providing education on postoperative care.
Choice A (acute pancreatitis) would require specific knowledge and skills related to the gastrointestinal system, which may not be within the RN's expertise from the maternal-newborn unit. Choice C (stroke admission) would require expertise in neurology and rehabilitation, which may not be the RN's area of focus. Choice D (end-stage renal disease) would require expertise in nephrology and dialysis, which may not be the RN's specialty.
Assigning the RN to a client who is postoperative following a total abdominal hysterectomy aligns with the RN's background in maternal
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A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
- A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
- B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
- C. Collect a stool sample for ova and parasites from a school-age child
- D. Engage a toddler in play.
Correct Answer: A
Rationale: The correct answer is A: Check to see if the elbow restraint is in place for an infant postoperative from a surgical correction of a cleft palate. This task should be performed first because it involves the safety and well-being of the infant. Elbow restraints are crucial post-surgery to prevent the infant from inadvertently touching or injuring the surgical site. Ensuring the elbow restraint is in place promptly is essential to prevent complications and promote healing.
The other choices are incorrect because they do not prioritize the immediate safety and well-being of a postoperative infant. Washing the hair of an adolescent, collecting a stool sample, and engaging a toddler in play are important tasks but can be done after ensuring the safety of the postoperative infant. It is crucial to prioritize tasks based on the urgency and potential impact on the client's health and safety.
A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
- A. A client who has pneumonia and has an axillary temperature of 38° C (101° F)
- B. A client who has diarrhea and requests clear liquids for breakfast
- C. A client who has a cast on the left leg and reports numbness and paresthesia
- D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
Correct Answer: C
Rationale: The correct answer is C because numbness and paresthesia in a client with a cast can indicate compartment syndrome, a medical emergency requiring immediate attention to prevent tissue damage or loss of limb. This condition can lead to permanent disability if not addressed promptly. Clients with pneumonia (choice A) and elevated temperature can be managed with antipyretics and antibiotics, while a client with diarrhea (choice B) requesting clear liquids can be managed with dietary adjustments. A client with type 1 diabetes and a blood glucose level of 150 (choice D) may require insulin adjustment but is not as urgent as addressing potential compartment syndrome.
A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
- A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output
- B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL
- C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache
- D. A client who was administered acyclovir for cellulitis reports pain in the affected leg
Correct Answer: B
Rationale: The nurse should assess the client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL first. Hypoglycemia (low blood sugar) can lead to serious complications, including confusion, seizures, and loss of consciousness. Immediate intervention is necessary to prevent further deterioration. Choice A could indicate hematuria, which also requires attention but is not immediately life-threatening. Choices C and D do not present immediate life-threatening situations.
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?
- A. There are no provider's prescriptions available.
- B. The client was found unconscious on the floor in her home.
- C. The client should be seen by a neurologist.
- D. The client is disoriented. Pupils are slow to respond to light.
Correct Answer: D
Rationale: The correct answer is D because in the SBAR communication tool, the "B" step stands for Background. Reporting the client's disorientation and slow pupil response to light provides essential background information for the provider to understand the client's condition. This information helps the provider assess the urgency and severity of the situation. Choice A is incorrect because it does not provide relevant client information in the Background step. Choices B and C belong in the S (Situation) step as they directly relate to the client's current situation and recommended actions. Therefore, they are not appropriate for the Background step.
A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- A. Blood for PaCO2
- B. Random stool specimen
- C. Wound drainage for culture
- D. Urine from an indwelling catheter
Correct Answer: B
Rationale: The correct answer is B: Random stool specimen. The rationale is that collecting a random stool specimen does not require specialized training or skills, making it appropriate for assistive personnel (AP) to perform. Collecting blood for PaCO2 (A) requires specific training and knowledge of arterial blood gas sampling. Wound drainage for culture (C) involves sterile technique and knowledge of wound care. Urine from an indwelling catheter (D) requires knowledge of catheter care and sterile technique. Therefore, delegating the collection of a random stool specimen to AP is the most appropriate choice.