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A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family provides the client's signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Client's healthcare power of attorney.
- B. Increasing confusion of the client.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: B
Rationale: Increasing confusion is the urgent situation, indicating potential neurological deterioration.
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The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?
- A. The number of clients leaving the unit for diagnostic tests.
- B. The acuity level of the clients on the unit.
- C. The physician's plans to perform procedures on the unit.
- D. The skill level of the personnel staffing the unit.
Correct Answer: B
Rationale: Client acuity determines the intensity of care needed, critical for staffing decisions.
The registered nurse (RN) is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the emergency department (ED) nurse calls to report on a client with unstable angina who must be admitted immediately. A practical nurse (PN) and unlicensed assistive personnel (UAP) are available to the RN. How should the RN assign the necessary nursing actions?
- A. Assign the UAP to prepare the room while the PN obtains report on the new admission and the RN assists with the thoracentesis.
- B. Assign the UAP to assist with the thoracentesis while the PN goes to the ED to transport the client to the unit and the RN obtains report from the ED nurse.
- C. Assign the PN to assist with the thoracentesis while the RN obtains report and the UAP prepares the room for the new admission.
- D. Assign the PN to go to the ED to obtain report and transport the client while the UAP prepares the room and the RN assists with the thoracentesis.
Correct Answer: D
Rationale: The PN can handle report and transport, the UAP can prepare the room, and the RN is needed for the thoracentesis.
An unlicensed assistive personnel (UAP) who is working on a skilled nursing unit is diagnosed with hepatitis A (HVA). Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. Which action should the nurse-manager take next?
- A. Observe the nurse for jaundice and icterus sclera.
- B. Review the immunization status of all unit employees.
- C. Refer the nurse to employee health for serological testing.
- D. Post an employee notice of the outbreak of HVA on the unit.
Correct Answer: C
Rationale: Serological testing confirms HVA, enabling prompt diagnosis and treatment.
A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?
- A. The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.
- B. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dL (10.8 mmol/L).
- C. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
- D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
Correct Answer: D
Rationale: The pneumothorax client with low oxygen saturation is at risk of respiratory failure, requiring immediate assessment.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
- A. Review the medication transcription with the nurse.
- B. Evaluate the client for symptoms of a drug interaction.
- C. Report the medication error to the nursing supervisor.
- D. Inform the pharmacist who dispensed the medication.
Correct Answer: C
Rationale: Reporting the error ensures proper documentation and follow-up for client safety.