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A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?
- A. I have my assignment and will start with room 1, then work my way to room 10.
- B. After breakfast, I will pack the belongings of clients who will be discharged this morning.
- C. I will start by providing partial baths before breakfast.
- D. I will give this client his meal tray first, as he is going early to physical therapy.
Correct Answer: A
Rationale: The correct answer is A because the AP's statement lacks prioritization based on client needs or acuity. Starting with room 1 and working way to room 10 may not address urgent needs. Choice B demonstrates an understanding of the timely task of packing for discharged clients. Choice C indicates a proactive approach to hygiene needs. Choice D highlights prioritizing based on a client's scheduled activity. Overall, choice A lacks a clear understanding of prioritization in client care, making it the correct answer.
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A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?
- A. The physiologic status of the clients on the unit
- B. Social relationships between nurses working the oncoming shift
- C. Personal comfort level in making the assignments
- D. The most experienced nurse receives the more complex clients
Correct Answer: A
Rationale: The correct answer is A. The charge nurse should consider the physiologic status of the clients on the unit when making assignments to ensure that each client receives appropriate care based on their health condition. This factor is crucial for patient safety and outcomes. Choice B is incorrect as social relationships between nurses should not influence patient assignments. Choice C is incorrect as personal comfort level should not drive assignment decisions, rather patient needs should. Choice D is incorrect as assigning more complex clients based solely on experience may not always be the best approach, as other factors like workload and skill mix should also be considered.
A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
- A. Apply an ambulation alarm to the client's leg.
- B. Obtain a prescription to restrain the client PRN.
- C. Instruct the client in the use of the call light.
- D. Raise all side rails on the client's bed.
- E. Check on the client hourly.
Correct Answer: A,C,E
Rationale: The correct actions are A, C, and E. Applying an ambulation alarm to the client's leg helps prevent falls by alerting staff when the client attempts to get out of bed. Instructing the client in the use of the call light promotes safety by enabling them to request assistance when needed. Checking on the client hourly allows for monitoring and timely intervention if the client is at risk of falling. Choice B, obtaining a prescription to restrain the client PRN, is incorrect as physical restraints can have adverse effects and should be used as a last resort. Choice D, raising all side rails on the client's bed, is incorrect because it may lead to feelings of confinement and is not recommended as a fall prevention strategy.
A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change?
- A. Set a target date.
- B. Use tactics to alert staff nurses that a change is needed.
- C. Evaluate the effectiveness of the change.
- D. Assess the problem.
Correct Answer: A
Rationale: The correct answer is A: Set a target date. During the moving stage of change, setting a target date is crucial to create a sense of urgency and maintain momentum. It provides a clear timeline for implementation, ensuring accountability and focus. This action helps prevent delays and keeps the change process on track.
Choice B is incorrect because alerting staff nurses about the need for change is more relevant during the unfreezing stage. Choice C is incorrect as evaluating effectiveness typically occurs during the refreezing stage. Choice D is incorrect as assessing the problem is part of the initial stages of change management, not the moving stage.
A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
- A. WBC 6,000/mm3
- B. BUN 15 mg/dL
- C. Hemoglobin 14 g/dL
- D. Platelet count 60,000/mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet count 60,000/mm3. A low platelet count (thrombocytopenia) can increase the risk of bleeding during surgery. Normal platelet count is around 150,000-450,000/mm3. The other options are within normal ranges: A) WBC 6,000/mm3 is normal, B) BUN 15 mg/dL is normal, and C) Hemoglobin 14 g/dL is normal. Therefore, the nurse should follow up on the platelet count to ensure the client's safety during surgery.
A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?
- A. Assigning the most competent RN to perform a central line dressing change
- B. Assigning the most efficient AP to perform glucometer monitoring for each client
- C. Assigning two assistive personnel (AP) to ambulate all clients
- D. Assigning a new graduate nurse to perform a wet-to-dry dressing change
Correct Answer: D
Rationale: Correct Answer: D - Assigning a new graduate nurse to perform a wet-to-dry dressing change.
Rationale:
1. Wet-to-dry dressing changes require advanced skill and knowledge.
2. New graduate nurses may not have sufficient experience to perform this task safely.
3. Risk of complications such as infection or tissue damage is higher with inexperienced staff.
Summary of Other Choices:
A: Assigning the most competent RN to perform a central line dressing change - Competent RNs are appropriate for this task.
B: Assigning the most efficient AP to perform glucometer monitoring - Routine task suitable for AP.
C: Assigning two AP to ambulate all clients - Ensures safety and efficiency in patient care.