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A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?
- A. A client who has gestational diabetes and is receiving biweekly nonstress tests
- B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
- C. A client who is at 32 weeks of gestation and has premature rupture of membranes
- D. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
Correct Answer: D
Rationale: The correct answer is D because the RN from a medical-surgical unit would have experience managing postoperative care and understanding the complexities of a patient with a PCA pump. Choice A involves monitoring nonstress tests which are more routine and can be handled by other staff. Choice B requires specific knowledge of preeclampsia and labor induction medications. Choice C involves managing premature rupture of membranes which requires obstetrical expertise. Overall, choice D is the most appropriate for the RN who has floated from a medical-surgical unit due to their experience with postoperative care and pain management.
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A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
- A. Decreased level of consciousness
- B. Report of photophobia
- C. Increased temperature
- D. Generalized rash over trunk
Correct Answer: A
Rationale: The correct answer is A. A decreased level of consciousness in a client with meningitis indicates a severe neurological deterioration, possibly due to increased intracranial pressure. Immediate intervention is crucial to prevent further complications like brain damage or herniation. Reporting this to the provider facilitates prompt assessment and treatment. Choices B, C, and D are also common in meningitis but are not immediate concerns. Photophobia and increased temperature are typical symptoms, while a rash may indicate a different condition like viral exanthem.
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 conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.
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 assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?
- A. Erythema on the skin surrounding a client's wound
- B. Deep red color on the center of a client's wound
- C. Increase in serosanguineous exudate from a client's wound
- D. Inflammation noted on the tissue edges of a client's wound
Correct Answer: B
Rationale: The correct answer is B: Deep red color on the center of a client's wound. This finding indicates wound healing as it suggests the formation of granulation tissue, which is essential for the wound healing process. Granulation tissue is rich in blood vessels and appears deep red in color. This indicates that the wound is in the proliferative phase of healing.
Choice A - Erythema on the skin surrounding a client's wound - Erythema typically indicates inflammation and is not a clear sign of wound healing.
Choice C - Increase in serosanguineous exudate from a client's wound - Increased exudate may indicate inflammation or infection, not necessarily healing.
Choice D - Inflammation noted on the tissue edges of a client's wound - Inflammation suggests the wound is still in the inflammatory phase of healing, not the proliferative phase where granulation tissue forms.