Nokea
A nurse is leading a debriefing session after a critical incident on the unit. Which of the following actions should the nurse take to support the team?
- A. Focus on assigning blame for the incident.
- B. Encourage staff to share their feelings and experiences.
- C. Criticize staff for errors made during the incident.
- D. Limit the discussion to procedural changes only.
Correct Answer: B
Rationale: Encouraging staff to share their feelings and experiences promotes emotional support and team cohesion, helping staff process the incident and identify areas for improvement.
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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 teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching?
- A. A staff nurse can function as the incident commander.
- B. An actual disaster cannot take the place of a disaster drill.
- C. A physician must triage victims of a disaster in the emergency department.
- D. Disaster drills should be held on a regular basis.
Correct Answer: D
Rationale: The correct answer is D: Disaster drills should be held on a regular basis. This is essential for preparedness and practice in handling emergencies. Regular drills help ensure staff are familiar with procedures, can identify areas for improvement, and maintain readiness.
Incorrect choices: A: A staff nurse typically does not serve as the incident commander, who is usually a designated leader with specific training. B: While disaster drills are crucial, an actual disaster is unpredictable and serves a different purpose. C: Triage in a disaster is often done by trained personnel such as nurses or paramedics, not just physicians.
Admission Assessment
Vital Signs
Nurses' Notes
82-year-old client admitted with nondisplaced hip fracture awaiting surgery. History of mild dementia, and hypotension. The family is concerned about malnutrition and living alone. The client's daughter who is the power of attorney (POA) is currently out of state.
A nurse is caring for a client who is exhibiting increased agitation. The nurse offered toileting, lowered the lights in the client's room and closed door to client's room. The nurse is at risk for which of the following as evidenced by applying wrist restraints to the client?
- A. False imprisonment
- B. Slander
- C. Negligence
- D. Battery
- E. Assault
Correct Answer: A
Rationale: [1, 0, 0, 0, 0]
Correct Answer: A
Rationale: Applying wrist restraints without appropriate justification can lead to false imprisonment, violating the client's rights. Slander (B) is verbal defamation; Negligence (C) is failure to provide reasonable care; Battery (D) is physical harm; Assault (E) is the threat of harm.
A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
- A. Transporting a school-age client who is in traction to another department
- B. Reading a book to a preschool client who has AIDS
- C. Rocking an infant who was admitted for croup
- D. Playing a computer video game with an adolescent who has sickle cell disease
Correct Answer: A
Rationale: The correct answer is A because transporting a school-age client in traction requires specialized training to ensure proper handling and safety precautions. Traction devices are delicate and any mishandling could lead to injury. Reading a book to a preschool client with AIDS (B) promotes emotional support. Rocking an infant with croup (C) provides comfort. Playing a computer video game with an adolescent with sickle cell disease (D) promotes social interaction and distracts from pain.
A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?
- A. I have my assignment and will start with room 1, then work my way to room 10.
- B. After breakfast, I will pack the belongings of clients who will be discharged this morning.
- C. I will start by providing partial baths before breakfast.
- D. I will give this client his meal tray first, as he is going early to physical therapy.
Correct Answer: A
Rationale: The correct answer is A because the AP's statement lacks prioritization based on client needs or acuity. Starting with room 1 and working way to room 10 may not address urgent needs. Choice B demonstrates an understanding of the timely task of packing for discharged clients. Choice C indicates a proactive approach to hygiene needs. Choice D highlights prioritizing based on a client's scheduled activity. Overall, choice A lacks a clear understanding of prioritization in client care, making it the correct answer.