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A nurse is caring for a client who is postoperative and reports a pain level of 8 on a scale of 0 to 10. Which of the following actions should the nurse take first?
- A. Administer the prescribed analgesic.
- B. Notify the provider of the pain level.
- C. Reposition the client for comfort.
- D. Document the pain level in the medical record.
Correct Answer: A
Rationale: The correct answer is A: Administer the prescribed analgesic first. Managing pain is a priority to ensure the client's comfort and prevent complications. Administering the analgesic promptly is essential to relieve the client's pain and improve their overall well-being. Notifying the provider (B) can be done after addressing the immediate need for pain relief. Repositioning the client (C) may provide some comfort but should come after administering pain medication. Documenting the pain level (D) is important, but addressing the pain itself takes precedence.
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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 charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?
- A. Providing a back rub to a client who has right-sided paralysis
- B. Transporting a client who experienced a stroke 72 hr ago to the radiology department
- C. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm
- D. Removing and cleaning the cannula of a client who has a new tracheostomy
Correct Answer: D
Rationale: The correct answer is D because removing and cleaning the cannula of a client with a new tracheostomy requires specialized skills and knowledge that only a licensed nurse possesses to prevent complications and ensure safety. Providing a back rub (A) can be delegated to an AP as it is within their scope of practice. Transporting a stroke client (B) and performing oral hygiene post-amputation (C) can also be delegated as they do not involve complex nursing assessments or interventions. It is crucial to reassign the tracheostomy care task to a licensed nurse to maintain the client's airway safely.
A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?
- A. Do you know when I will be going home?
- B. My dressing was changed earlier this morning.
- C. I have not received any of my medications today.
- D. I do not know how to make the remote control work.
Correct Answer: C
Rationale: Correct Answer: C. "I have not received any of my medications today."
Rationale: This statement is concerning as it indicates a potential oversight in medication administration, which is crucial for postoperative clients. The nurse should follow up with the PN to ensure that the client receives the necessary medications promptly.
Summary of Other Choices:
A: Asking about discharge is appropriate and does not require immediate follow-up.
B: Reporting that the dressing was changed is a positive sign of wound care management.
D: Not knowing how to use the remote control is not a priority in postoperative care.
Overall, choice C stands out as it directly relates to the client's well-being and should be addressed promptly.
A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?
- A. Tell other nurses what an effective team member the AP is.
- B. Detail the AP's contributions to the nurse manager.
- C. Nominate the AP for the Employee of the Month award.
- D. Give positive feedback directly to the AP.
Correct Answer: D
Rationale: The correct answer is D: Give positive feedback directly to the AP. This is the first action the nurse should take because it directly acknowledges and reinforces the AP's contributions. Providing feedback directly shows appreciation and motivates the AP to continue their excellent work. It helps build a positive relationship and boosts morale.
Choice A is less effective as it does not directly recognize the AP's efforts and may not reach the AP. Choice B involves an intermediary and may delay recognition. Choice C is a formal recognition and may not provide immediate feedback to the AP. Thus, giving direct positive feedback to the AP is the most immediate and impactful way to recognize their contributions.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.