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A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?
- A. The emergency department nurse is waiting to give report on a new admission.
- B. Two staff members have called to say they will be absent.
- C. A nurse on the previous shift wrote an incident report about a medication error.
- D. Transport assistance is unavailable to take a client to occupational therapy.
Correct Answer: A
Rationale: The correct answer is A because the charge nurse should address urgent situations first. The emergency department nurse waiting to give report on a new admission indicates a critical patient needing immediate attention. Addressing this first ensures timely and appropriate care for the patient. Choices B and D, staff absences and transport assistance availability, can be managed after addressing the urgent patient situation. Choice C, the incident report about a medication error, is important but not as time-sensitive as the new admission report. Therefore, the charge nurse should prioritize addressing the emergency department nurse's report first.
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A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
- A. Determine the reasons the nurses are not taking scheduled breaks.
- B. Provide coverage for the nurses' breaks.
- C. Review facility policies for taking scheduled breaks.
- D. Discuss time management strategies with the nurses.
Correct Answer: A
Rationale: Determining the reasons for not taking breaks identifies the root cause, enabling targeted solutions to ensure staff well-being.
A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
- A. Offer to store the purse at the nurses' station.
- B. Tell the client to leave her purse in a drawer of the bedside table.
- C. Place the purse in the clothing bag with the client's other belongings.
- D. Offer to place the purse in the facility safe.
Correct Answer: D
Rationale: The correct answer is D: Offer to place the purse in the facility safe. This is the best option as it ensures the client's belongings are kept secure during the surgery. Storing the purse at the nurses' station (A) may not guarantee its safety. Leaving the purse in a drawer (B) or clothing bag (C) can also pose a risk of theft. Placing it in the facility safe (D) is the most secure and professional solution to address the client's concern.
A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?
- A. Uses a sterile-gloved hand to adjust the back of the sterile gown
- B. Uses sterile forceps to pack sterile gauze into the wound
- C. Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape
- D. Sets up the sterile field 30 min prior to performing the dressing change
Correct Answer: B
Rationale: Using sterile forceps to pack gauze maintains sterility, reducing infection risk, unlike actions that breach sterile field integrity.
A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?
- A. A young adult client who is participating in a medical research study
- B. A middle adult client who leaves the facility against medical advice
- C. An adolescent client whose parents refuse a blood transfusion for religious reasons.
- D. An older adult client who has advance directives on file
Correct Answer: C
Rationale: Parental refusal of a blood transfusion for a minor creates an ethical dilemma, balancing autonomy and the minor's health, requiring ethics committee input.
A nurse is providing teaching to assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
- A. Secure the client's restraints with a square knot.
- B. Attach the restraints to the fixed portion of the frame of the client's bed.
- C. Remove the client's restraints every 2 hr.
- D. Allow 1 fingerbreadth between the restraint and the client's wrists.
Correct Answer: C
Rationale: The correct answer is C: Remove the client's restraints every 2 hr. This instruction is crucial to prevent complications such as skin breakdown, circulation impairment, and emotional distress. Restraints should be released every 2 hours to assess the client's condition, provide necessary care, and ensure safety. This practice also promotes mobility and prevents long-term consequences of prolonged restraint use.
Explanation for other choices:
A: Secure the client's restraints with a square knot - Incorrect. Restraints should be secured with a quick-release knot to ensure quick removal in case of an emergency.
B: Attach the restraints to the fixed portion of the frame of the client's bed - Incorrect. Restraints should be attached to the movable portion of the bed frame to allow for adjustments and prevent harm.
D: Allow 1 fingerbreadth between the restraint and the client's wrists - Incorrect. Restraints should be snug but not too tight to avoid injury or discomfort.