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A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
- A. Assess the staff nurses' knowledge deficit.
- B. Demonstrate use of the pump during medication administration.
- C. Plan an in-service education program on the unit.
- D. Pair an inexperienced nurse with an experienced nurse.
Correct Answer: A
Rationale: The correct answer is A: Assess the staff nurses' knowledge deficit. This is the priority action because it helps identify the root cause of the difficulty with the new IV infusion pumps. By assessing the staff nurses' knowledge deficit, the charge nurse can determine if additional training, education, or support is needed. This step is crucial in addressing the problem effectively and ensuring safe medication administration.
Other choices:
B: Demonstrating the use of the pump during medication administration may be helpful but should come after assessing the knowledge deficit.
C: Planning an in-service education program is important but should be based on the assessment of the staff nurses' knowledge deficit.
D: Pairing an inexperienced nurse with an experienced nurse may be beneficial but does not directly address the underlying issue of knowledge deficit.
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A nurse is caring for a client who is scheduled for placement of a central venous access device. Which of the following actions is the nurse's responsibility in the informed consent process?
- A. Assess the client's understanding after the provider has talked with her.
- B. Discuss alternative treatment options with the client.
- C. Review the risks and benefits of the procedure with the client.
- D. Place a photocopy of the signed informed consent in the client's medical record.
Correct Answer: A
Rationale: Correct answer: A
Rationale: The nurse's responsibility in the informed consent process is to assess the client's understanding after the provider has discussed the procedure with the client. This step ensures that the client has comprehended the information provided by the provider, clarifies any uncertainties, and confirms the client's voluntary agreement to the procedure. It is crucial for the nurse to confirm the client's understanding to uphold the principles of autonomy and informed decision-making in healthcare.
Summary of other choices:
B: Discussing alternative treatment options is a responsibility of the provider, not the nurse in the informed consent process.
C: Reviewing risks and benefits of the procedure is typically done by the provider during the informed consent process.
D: Placing a photocopy of the signed informed consent in the client's medical record is important but does not directly involve the nurse's role in the informed consent process.
A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
- A. A prescribed consultation
- B. The client's vital signs
- C. The client's name
- D. The client's code status
Correct Answer: D
Rationale: The correct answer is D: The client's code status. In the background portion of an SBAR report, the nurse should include the client's code status to inform the receiving unit about the client's preferences for resuscitation in case of an emergency. This information is crucial for providing appropriate and individualized care.
A: A prescribed consultation is typically included in the assessment or recommendations sections of the SBAR report, not the background.
B: The client's vital signs are typically included in the assessment section to provide current physiological data.
C: The client's name is already known and is not necessary in the background portion of the report.
E, F, G: These choices are not applicable to the background portion of the SBAR report.
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.
A nurse is teaching a newly licensed nurse about the role of nurses during a facility disaster. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. A nurse should communicate with the performance improvement committee during a disaster to improve client outcomes.
- B. A nurse can recommend clients who are stable for discharge during a disaster.
- C. A unit nurse has the authority to prescribe emergency medications during a disaster.
- D. A unit nurse can provide information to the media during a disaster.
Correct Answer: B
Rationale: The correct answer is B because a nurse can recommend clients who are stable for discharge during a disaster to free up resources for more critical patients. This shows an understanding of prioritizing care and resource allocation in emergency situations. Choice A is incorrect because the performance improvement committee is not directly involved in disaster response. Choice C is incorrect because prescribing medications is outside the scope of a nurse's authority. Choice D is incorrect because providing information to the media is usually handled by designated spokespersons, not unit nurses.
A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
- A. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.
- B. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
- C. A nurse explains to a client's family that a DNR order includes withholding comfort measures.
- D. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
Correct Answer: C
Rationale: The correct answer is C. This is the only behavior that goes against ethical practice in this scenario. The charge nurse should recognize the need for further education when a nurse incorrectly explains that a DNR order includes withholding comfort measures, as this is inaccurate information. Justification for other choices: A is incorrect because it shows compassionate care. B is incorrect because it demonstrates appropriate pain management for a terminally ill client. D is incorrect because nurses have the right to refuse participation in procedures that go against their beliefs.