NCLEX-RN

Category - Care Management

Nina the New Nurse feels as if she is being drawn and quartered! Since she can’t divide herself into four separate nurses, in which order should these clients be seen?

I.. 82-year-old, admitted for chronic heart failure, receiving furosemide 40 mg, PO, daily. Nursing assistant (NA) reports a two pound decrease in weight since yesterday morning.
II.. 32-year-old, admitted for open reduction of fractured femur. History of schizophrenia. Licensed practical nurse (LPN) reports increased temperature (101.2F) and slight tremors; client is complaining of stiff jaw and muscle cramps.
III. 50-year-old, newly diagnosed IDDM, notified by NA client is requesting further dietary guidance and assistance with menu choices.
IV. 61-year-old, open inguinal hernia repair, one-day post-op. Unit secretary advising that the client has requested medication for surgical pain.
  1. I, III, IV, II
  2. IV, I, II, III
  3. III, IV, I, II
  4. II, IV, III, I
Explanation
Answer: D -Nurses are responsible for providing (or managing) care to meet their clients’ needs, regardless of whether the nurse is caring for a client personally or through delegation of duties. It is the nurse’s duty to understand the scope of practice for each member of the team. Based on the LPN’s report, the 32-year-old client requires immediate assessment; the signs and symptoms could indicate neuroleptic malignant syndrome (NMS), a potentially life-threatening adverse reaction associated with some antipsychotic medications.
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