Nokea
A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?
- A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
- B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
- C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
- D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.
Correct Answer: C
Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.
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While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?
- A. Remove the client from the room immediately.
- B. Leave the client's room to obtain a fire extinguisher.
- C. Instruct a nurse tech to pull the fire alarm.
- D. Evacuate all clients from the unit.
Correct Answer: A
Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.
While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?
- A. Recommend a dermatological consult to the physician.
- B. Note the location of the mole and contact the physician via telephone.
- C. Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
- D. Remove the mole with a sharp debridement technique, following approval from the charge nurse.
Correct Answer: C
Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.
A child with newly diagnosed leukemia is receiving chemotherapy. Which would be included in his plan of care by the nurse?
- A. Place the child in a negative pressure isolation room
- B. Administer prophylactic IV antibiotics
- C. Avoid high protein food intake
- D. Teach family and visitors handwashing techniques
Correct Answer: D
Rationale: The correct answer is to teach family and visitors handwashing techniques. Any client on chemotherapy should have good infection control measures in place, such as handwashing by all who they encounter. Placing the child in a negative pressure isolation room (Choice A) is not necessary unless specifically indicated for a certain condition. Administering prophylactic IV antibiotics (Choice B) may not be part of the standard care plan for a child with leukemia receiving chemotherapy. Avoiding high protein food intake (Choice C) is not directly related to infection control and may not be necessary unless there are specific dietary restrictions.
A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:
- A. Obtaining Intake and Output.
- B. Frequent lung assessments.
- C. Vital signs every shift.
- D. Monitoring the IV site for infiltration.
Correct Answer: D
Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.
A client with sleep apnea has been ordered a CPAP machine. Which action could the RN delegate to a nursing assistant?
- A. Reminding the client to apply the CPAP at bedtime
- B. Obtaining every three-hour oxygen saturation levels
- C. Teaching the client how to turn on the CPAP machine
- D. Assessing for fatigue or depression caused by poor sleep
Correct Answer: A
Rationale: The correct answer is reminding the client to apply the CPAP at bedtime. This task can be safely delegated to a nursing assistant as it involves a simple and routine reminder. Option B, obtaining oxygen saturation levels, requires a higher level of training and interpretation of results, making it more appropriate for an RN. Option C, teaching the client how to turn on the CPAP machine, involves educating the client and ensuring proper use of medical equipment, which is within the RN's scope of practice. Option D, assessing for fatigue or depression, requires a comprehensive evaluation that involves interpreting symptoms and identifying underlying causes, making it more suitable for an RN to address.