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A nurse is caring for a client who is postoperative and has a chest tube. The nurse notes that the chest tube is disconnected from the drainage system. Which of the following actions should the nurse take first?
- A. Reconnect the chest tube to the drainage system.
- B. Clamp the chest tube near the insertion site.
- C. Notify the provider of the disconnection.
- D. Place the end of the chest tube in sterile water.
Correct Answer: D
Rationale: Placing the end of the chest tube in sterile water prevents air from entering the pleural space, which could cause a pneumothorax, making it the priority action.
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An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?
- A. The client who is in protective isolation
- B. The client who is actively dying and requires IV pain medication
- C. The client who is 3 days postoperative and requires a dressing change
- D. The client who requires frequent ambulation
Correct Answer: B
Rationale: The correct answer is B: The client who is actively dying and requires IV pain medication. The RN should assume responsibility for this client because as the registered nurse, they are the most qualified to manage complex care needs, such as IV pain medication administration and end-of-life care. The RN's advanced knowledge and skills make them best suited to provide appropriate assessment, intervention, and coordination of care in this critical situation.
Choice A is incorrect because the client in protective isolation requires meticulous adherence to infection control practices, which can be safely delegated to the LPNs or AP under the RN's supervision.
Choice C is incorrect as a dressing change for a client 3 days postoperative is within the scope of practice for the LPNs or AP and does not require the RN's direct involvement.
Choice D, the client requiring frequent ambulation, can be delegated to the LPNs or AP, as this task does not require the RN's specialized skill set.
A nurse is caring for a client who is postoperative and has a new prescription for incentive spirometry. Which of the following tasks should the nurse perform?
- A. Teach the client how to use the incentive spirometer.
- B. Assist the client with ambulation to the hallway.
- C. Measure the client's oxygen saturation every 4 hours.
- D. Document the client's daily intake and output.
Correct Answer: A
Rationale: Teaching the client how to use the incentive spirometer requires nursing expertise to ensure proper technique and understanding, which is essential for preventing postoperative complications like pneumonia.
A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?
- A. Discovery phase
- B. Decision phase
- C. Trial phase
- D. Complaint phase
Correct Answer: A
Rationale: The correct answer is A: Discovery phase. During the discovery phase of a legal process, both parties exchange information and evidence relevant to the case. A deposition is a part of the discovery phase where witnesses are questioned under oath. In this scenario, the nurse manager would be required to participate in a deposition to provide information related to the lawsuit.
Option B: Decision phase is incorrect as it typically refers to the phase where a judgment or verdict is made. Option C: Trial phase is incorrect as it involves the actual court proceedings. Option D: Complaint phase is incorrect as it is the initial phase where a formal complaint is filed to initiate the legal process.
A charge nurse is evaluating the performance of an assistive personnel (AP). Which of the following actions by the AP indicates a need for further education?
- A. The AP reports a client's temperature of 38.5°C to the nurse.
- B. The AP assists a client with turning every 2 hours.
- C. The AP leaves a client's meal tray out of reach after delivery.
- D. The AP uses a gait belt when ambulating a client.
Correct Answer: C
Rationale: Leaving the meal tray out of reach prevents the client from eating, indicating a need for further education on client-centered care. The other actions are appropriate.
A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?
- A. Compare the number of medication errors before and after the action was implemented.
- B. Conduct a study about the time and money costs of implementing the change.
- C. Establish a benchmark to identify a standard of performance.
- D. Provide the staff with a questionnaire to quantify staff satisfaction with the changes.
Correct Answer: A
Rationale: The correct answer is A: Compare the number of medication errors before and after the action was implemented. This method is effective in evaluating the success of the changes because it directly assesses the impact of the implemented measures on reducing medication errors. By comparing the number of errors before and after the changes, the nurse can determine if the interventions were successful in achieving the desired outcome.
Summary:
B: Conducting a study about the time and money costs is irrelevant to evaluating the success of reducing medication errors.
C: Establishing a benchmark is important for setting a standard but does not directly assess the effectiveness of the changes.
D: Providing staff with a questionnaire assesses satisfaction, not the actual impact on medication errors.