A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
A client who has COPD and the capillary refill time on both hands is 4 seconds
A client who has late-stage cirrhosis and whose breath has a fruity odor
A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
The Correct Answer is D
Rationale:
A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.
B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.
C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.
D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.
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Correct Answer is B
Explanation
Rationale:
A. Protective isolation could be managed by any qualified RN, LPN, or AP depending on the complexity.
B. A client actively dying and requiring IV pain medication needs specialized assessment and pain management, which is appropriate for an RN.
C. A client 3 days postoperative requires ongoing care that can be managed by an LPN with supervision.
D. Frequent ambulation is a task that can be managed by an AP, though supervision may be needed.
Correct Answer is D
Explanation
Rationale:
A. Telling other nurses is useful for team morale but does not directly recognize the AP.
B. Detailing contributions to the manager is valuable but can be done after initial direct recognition.
C. Nominating for an award is an excellent formal recognition but should follow immediate feedback.
D. Giving direct positive feedback immediately acknowledges the AP’s efforts and encourages continued good performance.