Correct Answer: C

Rationale: The correct answer is C: A client with chest pain and shortness of breath. This client should be prioritized for immediate care as chest pain and shortness of breath can indicate a potentially life-threatening condition such as a heart attack or pulmonary embolism. The nurse should assess and intervene promptly to prevent further complications.


Choice A is incorrect because a laceration on the arm with stable vital signs is not immediately life-threatening.
Choice B, a closed fracture of the femur with severe pain, while painful, does not pose an immediate threat to life.
Choice D, abrasions on the face and neck, are not considered priority over potential cardiac or respiratory issues.

Correct Answer: B

Rationale: The correct answer is B. Prioritizing follow-up on the assistive personnel's failure to report a client's low blood glucose level is crucial as it directly impacts patient safety and could lead to serious consequences. Not reporting a critical health issue promptly can result in harm or even death. Addressing this issue promptly is essential to prevent recurrence and ensure the well-being of the patient.

Choices A, C, and D involve errors or delays that are concerning but do not pose an immediate threat to patient safety compared to the failure to report a critical health issue.

Correct Answer: A

Rationale: The correct answer is A because encouraging a client to participate in treatment decisions empowers them to make informed choices about their care, promoting their autonomy and self-determination. This demonstrates client advocacy by ensuring the client's voice is heard and respected.


Choice B is incorrect as administering medications without client input disregards their right to be involved in their care decisions.
Choice C is incorrect as labeling a client's refusal of treatment as noncompliance lacks advocacy and may undermine the client's autonomy.
Choice D is incorrect as simply informing the provider that a client is uncooperative does not actively advocate for the client's best interests or involve them in decision-making.

Correct Answer: B

Rationale:
Correct
Answer: B


Rationale: The charge nurse should delegate assisting the client with ambulation to the bathroom to an assistive personnel (AP) as it is within the AP's scope of practice and does not require specialized nursing knowledge. This task helps promote the client's mobility and independence postoperatively. The AP can provide physical support and ensure the client's safety during ambulation.

Incorrect

Choices:
A: Assessing the client's incisional pain requires nursing judgment and assessment skills, which should be done by a licensed nurse.
C: Evaluating the client's response to pain medication involves assessing for effectiveness, side effects, and potential complications, which requires nursing knowledge and assessment skills.
D: Monitoring the client's surgical drain output involves assessing for signs of infection, leakage, or other complications that require nursing judgment and intervention.

Correct Answer: D

Rationale: The correct answer is D: Provide the client with a quiet environment. This task can be delegated to an assistive personnel (AP) because it involves creating a suitable environment for the client, which does not require specialized nursing skills. Assisting the client in a quiet environment can help minimize triggers and promote calmness during alcohol withdrawal.

A: Monitoring vital signs every 4 hours requires nursing judgment to interpret the results and decide on appropriate interventions.
B: Administering a benzodiazepine is a medication administration task that should be done by a nurse who can assess the client's condition and response to the medication.
C: Assessing the client for tremors or agitation involves clinical judgment and requires a nurse's expertise to determine the appropriate interventions.

In summary, providing a quiet environment is a task that can be safely delegated to an assistive personnel, while the other options involve assessments, medication administration, and clinical judgment that are within the scope of nursing practice.