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A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?
- A. Determine the social skills of the AP.
- B. Assess the AP's ability to follow the client's teaching plan.
- C. Provide a clear description of the task to the AP.
- D. Evaluate the ability of the AP to work with peers.
Correct Answer: C
Rationale: The correct answer is C: Provide a clear description of the task to the AP. This is essential in delegation to ensure the AP understands what is expected. Determining social skills (A) and evaluating ability to work with peers (D) are not directly related to task delegation. Assessing ability to follow a teaching plan (B) is important but not the primary focus in task delegation.
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A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate?
- A. If you let us know ahead of time that you plan to perform a procedure, we could do better job of having the supplies available.
- B. It must be very frustrating when you don't have want you need to perform the procedure.
- C. I will help you with this procedure instead of the staff nurse.
- D. You should think about how you make others feel when you lose your temper.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and understanding towards the staff nurse's frustration. By acknowledging the staff nurse's feelings and showing empathy, the charge nurse can diffuse the situation and work towards finding a solution collaboratively.
Choice A is not as appropriate because it may come across as blaming the staff nurse for the lack of supplies. Choice C is not ideal as it doesn't address the underlying issue of the incorrect supplies. Choice D shifts the focus away from the situation at hand and onto the provider's behavior.
In summary, choice B is the best response as it shows empathy, validates the staff nurse's feelings, and opens the door for constructive problem-solving.
A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?
- A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min
- B. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
- C. A toddler who has otitis media, a temperature of 39.2 C (102.6° F), and purulent ear discharge
- D. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough
Correct Answer: D
Rationale: The correct answer is D. Acute epiglottitis is a medical emergency due to potential airway compromise. The child's drooling and absence of cough indicate a severe obstruction that can rapidly progress to complete airway closure. Immediate intervention is crucial to prevent respiratory distress or arrest. Choices A, B, and C have less urgent conditions that can be managed after ensuring the child with epiglottitis receives prompt care. Choice A, although having asthma, is stable with adequate oxygenation. Choice B, although in pain, can wait briefly for pain medication. Choice C, although having otitis media, does not present immediate life-threatening risk compared to epiglottitis.
A nurse manager is reviewing incident reports from the past month. Which of the following situations should the nurse prioritize for follow-up?
- A. A client received a meal tray with the wrong diet.
- B. An assistive personnel failed to report a client's low blood glucose level.
- C. A nurse documented a medication administration 30 minutes late.
- D. A client's call light was answered after a 10-minute delay.
Correct Answer: B
Rationale: The correct answer is B. Prioritizing follow-up on the assistive personnel's failure to report a client's low blood glucose level is crucial as it directly impacts patient safety and could lead to serious consequences. Not reporting a critical health issue promptly can result in harm or even death. Addressing this issue promptly is essential to prevent recurrence and ensure the well-being of the patient. Choices A, C, and D involve errors or delays that are concerning but do not pose an immediate threat to patient safety compared to the failure to report a critical health issue.
A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
- A. The client works in the hospital radiology department.
- B. The client discussed having prior thoughts of suicide.
- C. The client's blood pressure and pulse have been fluctuating throughout the day.
- D. The client's family members have been present most of the day.
Correct Answer: C
Rationale: The correct answer is C because fluctuating blood pressure and pulse indicate unstable vital signs requiring close monitoring and immediate intervention. The nurse giving report is indicating that the client's condition is dynamic and may require frequent assessments and interventions, which necessitates the oncoming nurse assuming total care. Choices A, B, and D do not directly imply the need for total care and could potentially be managed by assistive personnel.
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.