Nokea
A charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?
- A. A client with multisystem failure secondary to a motor vehicle collision.
- B. A client in end-stage liver failure who is experiencing esophageal bleeding.
- C. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
- D. A client with chest tubes secondary to a stab wound to the chest.
Correct Answer: D
Rationale: The client with chest tubes has stable needs manageable by a new graduate with recent training. Multisystem failure, liver failure, and ARDS require advanced skills better suited to experienced nurses.
You may also like to solve these questions
The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?
- A. Ask the client why he does not want to be weighed.
- B. Instruct the UAP to weigh the client using a bed scale.
- C. Direct the UAP to delay weighing the client until later.
- D. Document that the client refused daily weights.
Correct Answer: B
Rationale: Using a bed scale accommodates the client's condition, ensuring accurate weight measurement without discomfort. Asking why, delaying, or documenting refusal do not address the need for timely data to monitor fluid status.
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.
A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?
- A. Demonstrate the proper use of personal protective equipment.
- B. Offer to assist the UAP with the collection of the specimen.
- C. Provide the UAP with the infection control policy.
- D. Determine the UAP's knowledge about HIV transmission.
Correct Answer: D
Rationale: Determining the UAP's knowledge about HIV transmission is the first step to address misconceptions and fears, enabling targeted education. Demonstrating PPE, assisting with collection, or providing policy are secondary actions that follow understanding the UAP's knowledge gaps.
After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?
- A. Facilitate a palliative care meeting with the client and healthcare provider.
- B. Remind the client that new treatments are being developed daily.
- C. Provide the healthcare provider with a copy of the client's bill of rights.
- D. Initiate a review of the situation by the hospital's ethics committee.
Correct Answer: D
Rationale: An ethics committee review mediates conflicts and protects client rights when the provider opposes the client's wishes. Palliative meetings, mentioning treatments, or providing rights are less effective in resolving the ethical dilemma.
An experienced, female practical nurse (PN) is hired to work on the surgical unit of a tertiary hospital. The first day she is working on the unit, the PN tells the charge nurse that she has excellent wound care skills. It is a busy day and a postoperative client needs to have a sterile dressing change. Which action is best for the charge nurse to take?
- A. Review the PN's skill checklist to assess for wound care competency.
- B. Watch the PN perform sterile wound care to validate her skill level.
- C. Tell the PN that past experience does not indicate ability to perform skills.
- D. Ask the PN to change the sterile dressing while the nurse is busy.
Correct Answer: B
Rationale: Observing the PN perform wound care ensures her skills meet standards, protecting client safety. Reviewing a checklist, dismissing experience, or delegating without verification are less effective.