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A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?
- A. Obtain the client's legal records for power of attorney.
- B. Give analgesic medications as needed (PRN).
- C. Discontinue the intravenous infusion.
- D. Ask the palliative care team to speak with the client.
Correct Answer: D
Rationale: Consulting palliative care respects the client's wish to avoid machines and provides holistic end-of-life support. Power of attorney, analgesics, and IV discontinuation are secondary or inappropriate.
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A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?
- A. Caution the nurse that one more tardiness will result in probational employment.
- B. Offer to switch the nurse's shift assignments to afternoons or evenings.
- C. Stress the expectation that the nurse will arrive on time for all scheduled shifts.
- D. Have the nurse sign a copy of the hospital employee attendance policy.
Correct Answer: C
Rationale: Stressing punctuality expectations communicates the importance of timeliness clearly and respectfully. Threatening probation is overly punitive, changing shifts may not solve the issue, and signing a policy is less effective than direct communication.
A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?
- A. Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
- B. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.
- C. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
- D. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
Correct Answer: C
Rationale: Shutting doors and keeping everyone in rooms follows the RACE protocol (Rescue, Alarm, Contain, Extinguish), containing the fire and protecting from smoke. Evacuating clients or using elevators during a fire risks exposure to danger.
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control. Play time, parent instruction, and room assignment are secondary.
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take first?
- A. Ensure transfer of the client's electronic chart code.
- B. Give a detailed report to the accepting nurse.
- C. Take the family to the client's new room.
- D. Give the client written information about end-of-life care.
Correct Answer: B
Rationale: Giving a detailed report ensures continuity of care, critical for the client's palliative needs. Transferring chart codes, escorting family, or providing written information are secondary to effective handoff.
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.