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A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?
- A. Make a copy of the incident report for the provider.
- B. Submit the incident report to the risk manager.
- C. Place the incident report in the client's chart.
- D. Document in the chart that an incidence report has been filed.
Correct Answer: B
Rationale: The correct answer is B: Submit the incident report to the risk manager. This is the appropriate action because the risk manager is responsible for analyzing incidents to identify potential risks and implementing strategies to prevent them in the future. Providing the report to the risk manager allows for a comprehensive review and implementation of necessary measures.
Choice A is incorrect because making a copy of the incident report for the provider does not ensure that the incident is properly analyzed and addressed. Choice C is incorrect as placing the incident report in the client's chart may not reach the appropriate personnel for further action. Choice D is incorrect because simply documenting in the chart that a report has been filed does not facilitate a comprehensive review by the risk management team.
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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 has received morning report on the following four clients. Which of the following clients should the nurse assess first?
- A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output
- B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL
- C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache
- D. A client who was administered acyclovir for cellulitis reports pain in the affected leg
Correct Answer: B
Rationale: The nurse should assess the client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL first. Hypoglycemia (low blood sugar) can lead to serious complications, including confusion, seizures, and loss of consciousness. Immediate intervention is necessary to prevent further deterioration. Choice A could indicate hematuria, which also requires attention but is not immediately life-threatening. Choices C and D do not present immediate life-threatening situations.
An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating?
- A. Agency policies for the LPN
- B. The documented experience level of the LPN
- C. The documented skill level of the LPN
- D. State Nurse Practice Act for the LPN
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Act for the LPN. This is the priority criterion because the Nurse Practice Act outlines the scope of practice for LPNs in a specific state, ensuring that the tasks delegated are within their legal scope. This helps to protect patient safety and ensures legal compliance.
A: Agency policies for the LPN - Agency policies are important but do not take precedence over legal requirements outlined in the Nurse Practice Act.
B: The documented experience level of the LPN - Experience level is important but does not guarantee legal authority to perform certain tasks.
C: The documented skill level of the LPN - Skill level is important but does not override legal limitations set by the Nurse Practice Act.
A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking?
- A. Prescribing naloxone to reverse the effects of the morphine
- B. Asking the client to sign the surgical consent form
- C. Delaying the surgery until a member of the client's family is reached
- D. Invoking implied consent
Correct Answer: D
Rationale: The correct answer is D: Invoking implied consent. Implied consent allows healthcare providers to proceed with urgent treatment when a patient is unable to provide informed consent and there is an immediate threat to the patient's life or health. In this scenario, the client requires urgent surgical intervention for a compression fracture, and the family cannot be reached. Therefore, the neurosurgeon may invoke implied consent to proceed with the surgery to prevent further harm to the client.
A: Prescribing naloxone to reverse the effects of the morphine is not necessary in this case as the morphine was given for pain management and does not interfere with the need for urgent surgical intervention.
B: Asking the client to sign the surgical consent form is not appropriate as the client may not be in a condition to provide informed consent due to the urgent nature of the surgery and the effects of the medication.
C: Delaying the surgery until a member of the client's family is reached may not be feasible if there
A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
- A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
- B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
- C. Collect a stool sample for ova and parasites from a school-age child
- D. Engage a toddler in play.
Correct Answer: A
Rationale: The correct answer is A: Check to see if the elbow restraint is in place for an infant postoperative from a surgical correction of a cleft palate. This task should be performed first because it involves the safety and well-being of the infant. Elbow restraints are crucial post-surgery to prevent the infant from inadvertently touching or injuring the surgical site. Ensuring the elbow restraint is in place promptly is essential to prevent complications and promote healing.
The other choices are incorrect because they do not prioritize the immediate safety and well-being of a postoperative infant. Washing the hair of an adolescent, collecting a stool sample, and engaging a toddler in play are important tasks but can be done after ensuring the safety of the postoperative infant. It is crucial to prioritize tasks based on the urgency and potential impact on the client's health and safety.