Nokea
A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries requires follow-up?
- A. Client received 2 mg morphine IV at 0900 for pain rated 6/10.
- B. Client's blood pressure is normal after medication administration.
- C. Client refused morning medications; provider notified.
- D. Client's wound dressing changed at 1100 per protocol.
Correct Answer: B
Rationale: Describing blood pressure as 'normal' is vague and lacks specific data, requiring follow-up to ensure accurate and complete documentation.
You may also like to solve these questions
A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?
- A. The nurse relinquishes accountability for client outcomes when care is delegated to an AP.
- B. The nurse should consider the AP's level of experience when making delegation decisions.
- C. The AP can provide client education about how to perform basic self-care to the client.
- D. The AP can re-delegate a task to another AP who has similar work experience.
Correct Answer: B
Rationale: The correct answer is B: The nurse should consider the AP's level of experience when making delegation decisions. This answer demonstrates an understanding of the key principle of delegation, which is to assign tasks based on the competency and skill level of the individual. Considering the AP's experience ensures safe and effective delegation.
Incorrect choices:
A: Incorrect because the nurse remains accountable for client outcomes even when delegating tasks.
C: Incorrect because client education should typically be done by licensed healthcare providers.
D: Incorrect because delegation should not involve re-delegating tasks to another uninvolved AP.
In summary, choice B reflects the importance of assessing the AP's competency when delegating tasks, ensuring safe and quality care.
A nurse manager along with members of the nurse practice committee are conducting a skills day for assistive personnel in the medical surgical unit to validate competency. Which skills demonstrated by assistive personnel require immediate follow-up. Select the '3' findings that require immediate follow-up.
- A. AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping.
- B. AP 2-Verifies with nurse the order in which protective equipment should be removed.
- C. AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room.
- D. AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing.
- E. AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit.
- F. AP 4-Successfully completed skills of simulation including emptying the client's trash can
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Option A requires follow-up because pulling the fire alarm before removing the client may result in leaving the client in a dangerous situation. Option D needs follow-up because not washing hands after assisting a client into bed can lead to the spread of infection. Option E warrants follow-up as not knowing the alarm locations could delay response to emergencies. Options B, C, and F are not immediate concerns as they demonstrate proper procedures or successful completion of tasks.
A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
- A. Evaluate the results.
- B. Brainstorm solutions.
- C. Implement a resolution.
- D. Identify the problem
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first step in conflict resolution as it allows the nurse manager to understand the root cause of the conflict between pharmacy and staff nurses. By identifying the problem, the nurse manager can gather relevant information, perspectives, and concerns from both parties. This step is crucial in developing an effective resolution strategy.
Choice A (Evaluate the results) is incorrect as evaluation should come after identifying the problem. Choice B (Brainstorm solutions) is premature without understanding the underlying issue. Choice C (Implement a resolution) should not be done before identifying the problem to ensure the solution addresses the actual conflict.
A nurse is caring for a client who is postoperative and has a chest tube. The nurse notes that the chest tube is disconnected from the drainage system. Which of the following actions should the nurse take first?
- A. Reconnect the chest tube to the drainage system.
- B. Clamp the chest tube near the insertion site.
- C. Notify the provider of the disconnection.
- D. Place the end of the chest tube in sterile water.
Correct Answer: D
Rationale: Placing the end of the chest tube in sterile water prevents air from entering the pleural space, which could cause a pneumothorax, making it the priority action.
A nurse is caring for a client who is refusing a blood transfusion due to religious beliefs. Which of the following actions should the nurse take?
- A. Administer the transfusion after obtaining a court order.
- B. Document the client's refusal and inform the provider.
- C. Convince the client to accept the transfusion for their health.
- D. Ask the client's family to persuade the client.
Correct Answer: B
Rationale: Documenting the refusal and informing the provider respects the client's autonomy and ensures appropriate follow-up, while adhering to ethical and legal standards.