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 C
Explanation
Rationale:
A. Providing appropriate resources is an outcome of effective delegation but not its primary purpose.
B. Promoting discharge teaching is not the primary purpose of delegation; it’s more about ensuring tasks are appropriately assigned.
C. Delegation permits a designated individual to meet a goal on your behalf, accurately reflecting the purpose of delegating tasks to others to achieve client care goals efficiently.
D. Decreasing health care costs may be an indirect benefit, but it is not the primary purpose of delegation.
Correct Answer is A
Explanation
Rationale:
A. Nuclear family refers to a family unit consisting of two parents and their children. This definition matches the description provided by the parents.
B. Intergenerational family includes multiple generations living together or having frequent contact, which is not the case here.
C. Blended family involves parents who have remarried and may include children from previous relationships, which does not apply here.
D. Extended family includes additional relatives beyond the nuclear family, such as grandparents, aunts, or uncles, which is not the case in this scenario.