As charge nurse, you are making the daily assignments on the medical-surgical unit. Which client is best assigned to a nurse who has floated from the post-anesthesia care unit (PACU)?

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: a 52-year-old client with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy. This assignment is best suited for a nurse who has floated from the post-anesthesia care unit (PACU) because this client may require close monitoring due to potential complications post-colonoscopy, such as bleeding, changes in vital signs, or need for immediate interventions. Nurses from the PACU are skilled in monitoring and managing clients post-procedure, making them ideal for this assignment. Option A (thalassemia major with deferoxamine infusion) would be better suited for a nurse familiar with administering specific medications and managing chronic conditions like thalassemia. Option B (multiple myeloma discharge teaching) requires knowledge of oncology and patient education. Option D (pernicious anemia admission) would benefit from a nurse experienced in managing hematological disorders and performing initial assessments. Educationally, understanding the rationale behind assigning specific patients to nurses based on their expertise is crucial for ensuring optimal patient outcomes and efficient use of staff resources. This question helps reinforce the importance of appropriate nurse-to-patient assignments based on individual patient needs and nurse competencies.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Transfuse Factor VII concentrate. The priority in a client with hemophilia A, a disorder where there is a deficiency in factor VIII, is to address the bleeding risk. Factor VII concentrate helps replace the deficient clotting factor, aiding in hemostasis and preventing further bleeding complications. This intervention is crucial in managing hemophilia-related bleeding, especially in the setting of a traumatic injury like a car accident. Option A) Transport to radiology for C-spine x-rays is not the priority as assessing the C-spine can wait until the bleeding risk is addressed. Option C) Type and cross-match for 4 units RBCs is not the priority as addressing the clotting factor deficiency takes precedence over potential blood transfusions. Option D) Infuse normal saline at 250 mL/hour is not the priority as it does not address the underlying issue of hemophilia and bleeding risk. Educationally, this question highlights the importance of prioritizing interventions based on the client's condition, emphasizing the critical nature of addressing the underlying pathophysiology in emergencies. Understanding the specific management strategies for clients with hemophilia is essential in providing safe and effective care in emergency situations.

Correct Answer: C

Rationale: The correct answer is C) The client's oxygen saturation is 87%. In a client with disseminated intravascular coagulation (DIC) associated with a gram-negative infection, a low oxygen saturation level of 87% indicates hypoxemia, which is a critical situation requiring immediate intervention. Hypoxemia can lead to tissue hypoxia, worsening the coagulation abnormalities in DIC. Therefore, addressing the oxygen saturation level is a priority to prevent further complications. Option A) There is no palpable radial or pedal pulse may suggest impaired circulation but does not address the immediate threat of hypoxemia in this scenario. Option B) The client complains of chest pain is concerning for a possible cardiac event, but hypoxemia takes precedence in the context of DIC and a gram-negative infection. Option D) There is mottling of the hands and feet is indicative of poor perfusion, which is important but not as immediately critical as addressing hypoxemia in this situation. In an educational context, understanding prioritization of care based on the client's condition is crucial for nurses, especially when dealing with complex conditions like DIC. Recognizing and addressing the most critical assessment findings promptly can significantly impact patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) A 69-year-old with chemotherapy-induced neutropenia who has an elevated oral temperature. This client should be assessed first because neutropenia (low white blood cell count) puts them at high risk for infections, and an elevated temperature could indicate the presence of an infection, which is a medical emergency in this case. Option A, the 26-year-old with thalassemia major, is stable and scheduled for a blood transfusion, which is not an immediate concern. Option B, the 44-year-old with sickle cell crisis awaiting a CT scan, is also stable for the moment and can wait for assessment. Option C, the 50-year-old with non-Hodgkin's lymphoma expressing emotional distress, while important, does not present an immediate physiological threat that requires urgent assessment compared to the risk of infection in the neutropenic patient. Educationally, this question highlights the importance of prioritizing patient care based on the urgency of the situation and the potential risks involved. It reinforces the significance of recognizing signs of infection in immunocompromised patients and the need for prompt assessment and intervention in such cases to prevent further complications.

Correct Answer: C

Rationale: In this scenario, the correct action to take first is to stop the transfusion (Option C). This is because the client is experiencing signs of a transfusion reaction, specifically a febrile non-hemolytic reaction. This type of reaction is characterized by symptoms such as flushing, chills, fever, and tachypnea, which align with the client's presentation. Stopping the transfusion is crucial to prevent the reaction from worsening and to ensure the client's safety. By halting the transfusion, the healthcare provider can assess the client's condition, confirm the diagnosis of a transfusion reaction, and initiate appropriate interventions. Option A (Obtain a warm blanket for the client) may provide comfort but does not address the underlying cause of the client's symptoms. Checking the client's oral temperature (Option B) could be useful information but is not the priority when a transfusion reaction is suspected. Administering oxygen (Option D) may be necessary if the client develops respiratory distress, but stopping the transfusion takes precedence to prevent further complications. In an educational context, understanding the signs and management of transfusion reactions is essential for nurses and healthcare providers who administer blood products. Rapid recognition and appropriate intervention can mitigate the severity of a reaction and promote positive patient outcomes. It is vital to prioritize patient safety and well-being in these situations by taking prompt and effective actions.