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 ["A","E"]
Explanation
Rationale:
A. The benchmark for glucose control is 90%, but the percentages reported are consistently below this threshold: 75.29% in Quarter 1, 85.5% in Quarter 2, and 82% in Quarter 3. Improvement is needed to meet or exceed the benchmark.
B. The benchmark is 80.2%, and the percentages are above this threshold: 75.79% in Quarter 1, 80.5% in Quarter 2, and 92% in Quarter 3. No improvement needed as the measure is above the benchmark.
C. The benchmark is 85%, and the percentages reported are: 69% in Quarter 1, 85% in Quarter 2, and 86.2% in Quarter 3. Although Quarter 1 is below the benchmark, Quarter 2 and Quarter 3 meet or exceed the benchmark. Overall, the trend shows improvement.
D. The benchmark is 100%, and the percentages reported are: 90.4% in Quarter 1, 88.2% in Quarter 2, and 92.6% in Quarter 3. Although the percentages are below the benchmark, there is a trend of improvement. However, the measure still requires further enhancement to meet the benchmark.
E. The benchmark for smoking cessation education 4 weeks prior to surgery is 75%. The percentages are below this benchmark in Quarter 1 (70.6%) and Quarter 3 (74%), although it meets the benchmark in Quarter 2 (100%). Consistent adherence to the benchmark needs to be improved.
Correct Answer is B
Explanation
Rationale:
A. The National Council of State Boards of Nursing Decision Tree provides guidance for decision-making but does not specifically address delegation.
B. The state Nurse Practice Act defines the scope of practice for RNs and LPNs and is essential for understanding what tasks can be delegated.
C. The Omnibus Budget Reconciliation Act of 1987 primarily pertains to nursing home regulations and does not directly address task delegation.
D. The National Association for Practical Nurse Education and Services focuses on LPN education and standards, but the state Nurse Practice Act is more directly relevant to delegation.