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A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
- A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast.
- B. Apply a condom catheter to a client who is incontinent.
- C. Deliver a clean voided urine specimen to the laboratory.
- D. Feed a client who has bilateral casts due to upper arm fractures.
Correct Answer: A
Rationale: The correct answer is A: Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. This task should be completed first because it involves monitoring a client's blood glucose level to ensure safe administration of insulin. Insulin administration is time-sensitive and should be based on current blood glucose levels to prevent hypoglycemia or hyperglycemia. This task directly impacts the client's immediate health and safety, making it the priority.
Summary of other choices:
B: Applying a condom catheter can be important but is not as time-sensitive or critical as monitoring blood glucose levels for insulin administration.
C: Delivering a clean voided urine specimen is important but can often wait until after more urgent tasks are completed.
D: Feeding a client with bilateral casts is important, but it is not as time-sensitive as monitoring blood glucose levels for insulin administration.
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A nurse is on the hospital quality and performance Improvement committee. The committee is reviewing compliance with prevention measures related to posterior cervical surgical site infections over the first 3 quarters of the year. Which measures should the nurse recognize that indicate the need for improvement compared to benchmarks? Select all that apply.
- A. Glucose control
- B. Intraoperative vancomycin
- C. Post operative normothermia
- D. Perioperative antibiotics
- E. Smoking cessation
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Glucose control, perioperative antibiotics, and smoking cessation are important prevention measures related to posterior cervical surgical site infections. Glucose control is crucial as hyperglycemia can impair immune function, leading to increased infection risk. Perioperative antibiotics help prevent surgical site infections by reducing bacterial load. Smoking cessation is vital as smoking impairs wound healing and increases infection risk. Intraoperative vancomycin (B) is not typically a prevention measure for surgical site infections in posterior cervical surgeries. Postoperative normothermia (C) is important for general patient care but is not specifically related to preventing surgical site infections in this context.
A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?
- A. Right circumstances
- B. Right supervision
- C. Right communication
- D. Right person
Correct Answer: B
Rationale: The correct answer is B: Right supervision. By checking with assistive personnel on the unit throughout the shift, the nurse is ensuring that tasks are being completed under their supervision. This demonstrates the nurse's responsibility to oversee and monitor the work of the assistive personnel, ensuring that tasks are being carried out correctly and safely. The other choices are incorrect because: A) Right circumstances pertains to ensuring the task is appropriate for delegation; C) Right communication involves clear instructions and feedback; D) Right person involves selecting the appropriate individual for the task.
A nurse manager is reviewing the unit's compliance with infection control protocols. Which of the following findings requires immediate intervention?
- A. An assistive personnel wears gloves while feeding a client.
- B. A nurse uses hand sanitizer before entering a client's room.
- C. A nurse reuses a disposable gown after leaving a client's room.
- D. A client's visitor washes their hands upon entering the room.
Correct Answer: C
Rationale: Reusing a disposable gown violates infection control protocols, as it risks cross-contamination. The other actions align with or exceed standard infection control practices.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
- A. A middle adult male who is diaphoretic and reports epigastric pain
- B. A toddler who has a laceration on his forehead and is screaming
- C. An adolescent female client who is belligerent and has slurred speech
- D. A young adult with a painful sunburn of his face and arms
Correct Answer: A
Rationale: The correct answer is A. The nurse should have the provider care for the middle adult male who is diaphoretic and reports epigastric pain immediately. Diaphoresis and epigastric pain can be signs of a heart attack or other serious cardiac issue, requiring urgent medical attention to prevent complications. The other choices do not present an immediate life-threatening situation. The toddler with a laceration can be addressed after stabilizing the critical client. The belligerent adolescent may need behavioral intervention but does not require immediate medical attention. The young adult with sunburn, while painful, is not a life-threatening condition that requires immediate provider care.
A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A. A client who has a small circular partial-thickness burn of the left calf
- B. A client who has a massive head injury and is experiencing seizures
- C. A client who has a splinted open fracture of left medial malleolus
- D. A client who has severe respiratory stridor and a deviated trachea
Correct Answer: D
Rationale: The correct answer is D: A client who has severe respiratory stridor and a deviated trachea. This client should be assessed first because stridor indicates airway obstruction, which can rapidly progress to respiratory failure. A deviated trachea suggests a possible tension pneumothorax, a life-threatening condition requiring immediate intervention to prevent further deterioration. Assessing and managing the airway takes priority over other injuries.
Incorrect choices:
A: A small circular partial-thickness burn of the left calf is a lower priority as it does not pose an immediate threat to life compared to airway compromise.
B: A massive head injury with seizures is serious but managing the airway is the priority in this scenario.
C: A splinted open fracture of the left medial malleolus is important but does not pose an immediate threat to life compared to airway and breathing concerns.