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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Rationale:
A. Comparing the number of medication errors before and after implementing changes provides a direct measure of the effectiveness of those changes.
B. Conducting a study on costs is relevant but not directly related to evaluating the effectiveness in reducing medication errors.
C. Establishing a benchmark is useful for setting standards but does not measure the impact of changes already implemented.
D. Quantifying staff satisfaction is important for assessing the acceptance of changes but does not directly measure the effectiveness in reducing errors.
Correct Answer is D
Explanation
Rationale:
A. Lean gently over the back of a chair sitting to one side of the room may appear disengaged or unprofessional.
B. Cross her arms over her chest is a closed posture that may seem defensive or unapproachable.
C. Stare at the people the announcement will affect the most can be intimidating or uncomfortable for others.
D. Sit in front of the group for the meeting and then stand for the announcement is effective for emphasizing the importance of the announcement and engaging the audience.