A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:

Correct Answer: C

Rationale: The dressing should not be reinforced without notifying the physician. The physician may decide to reinforce the dressing after assessing the amount of bleeding. Blood on the dressing is unusual, which should alert the nurse to do more than monitor the dressing. The physician should be notified immediately. If the bleeding persists, the client may need to return to surgery. The time and amount of blood needs to be recorded, but only after the physician is notified.

Correct Answer: A

Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.

Correct Answer: A

Rationale: In the context of nursing delegation, it is crucial to assign tasks to the appropriate personnel based on their competencies and scope of practice. In this scenario, option A, "Assist the child to remove outer clothing," is the most appropriate task to delegate to a nursing assistant. Nursing assistants are trained to provide basic care and assist with activities of daily living, such as helping patients dress or undress. This task does not require clinical judgment or specialized nursing knowledge, making it suitable for delegation to a nursing assistant. Options B, C, and D involve providing medical advice, explaining treatment rationale, and performing a nursing intervention requiring assessment and evaluation. These tasks fall within the scope of licensed nursing practice and should be performed by a registered nurse or other qualified healthcare provider. Delegating these responsibilities to a nursing assistant would be inappropriate and could compromise patient safety. Educationally, understanding the principles of delegation is essential for nursing students and practicing nurses to ensure safe and effective patient care delivery. By differentiating tasks based on complexity and required skill level, healthcare teams can optimize efficiency and promote patient well-being. It is critical for healthcare providers to adhere to established guidelines and standards when delegating tasks to support staff to uphold quality care standards.

Correct Answer: A

Rationale: In this scenario, the correct response is option A: "The ingested children's chewable vitamins contain iron." This information should be immediately reported to the physician because iron toxicity can be a serious and potentially life-threatening condition, especially in children. Iron overdose can lead to gastrointestinal symptoms, metabolic acidosis, cardiovascular collapse, and even death if not promptly treated. Therefore, notifying the physician about the ingestion of iron-containing vitamins is crucial for timely intervention and management. Option B, "The child has been treated several times for ingestion of toxic substances," while concerning, is not as immediately critical as ingesting iron. Option C, "The child has been treated several times for accidental injuries," does not pertain to the current situation of potential toxicity. Option D, "The child was nauseated and vomited once at home," is a common symptom post-ingestion but does not provide crucial information about the specific substance ingested, unlike the iron in this case. In an educational context, understanding the significance of reporting specific information to healthcare providers is vital for healthcare professionals, especially in emergency situations. This question highlights the importance of thorough assessment and prompt communication to ensure appropriate interventions and patient safety. Nurses and other healthcare providers must be able to prioritize and communicate critical findings effectively to optimize patient outcomes.

Correct Answer: D

Rationale: The correct answer is option D: Administer IV fluid support with supplemental thiamine as ordered. In this scenario, the patient is likely presenting with symptoms of alcohol withdrawal syndrome, which can lead to severe complications like delirium tremens. Administering IV fluid support helps to prevent dehydration and maintain electrolyte balance, while thiamine supplementation is crucial in preventing Wernicke's encephalopathy, a common complication of alcohol withdrawal. Option A: Obtaining an order for a blood alcohol level may be important for assessing the patient's alcohol intoxication status but is not the priority in managing acute alcohol withdrawal. Option B: Contacting the family for additional history is valuable for holistic care but does not address the immediate physiological needs of a patient experiencing alcohol withdrawal. Option C: Administering naloxone (Narcan) is used to reverse opioid overdose, not alcohol withdrawal symptoms. It is not indicated in this situation. Educationally, understanding the priority actions in managing alcohol withdrawal is essential for nurses caring for patients in acute care settings. Recognizing the signs and symptoms of withdrawal, and knowing the appropriate interventions, can help prevent severe complications and improve patient outcomes. Learning to prioritize interventions based on patient needs is a crucial skill in nursing practice.