Nokea
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?
- A. There are no provider's prescriptions available.
- B. The client was found unconscious on the floor in her home.
- C. The client should be seen by a neurologist.
- D. The client is disoriented. Pupils are slow to respond to light.
Correct Answer: D
Rationale: The correct answer is D because in the SBAR communication tool, the "B" step stands for Background. Reporting the client's disorientation and slow pupil response to light provides essential background information for the provider to understand the client's condition. This information helps the provider assess the urgency and severity of the situation. Choice A is incorrect because it does not provide relevant client information in the Background step. Choices B and C belong in the S (Situation) step as they directly relate to the client's current situation and recommended actions. Therefore, they are not appropriate for the Background step.
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A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
- A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
- B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
- C. Collect a stool sample for ova and parasites from a school-age child
- D. Engage a toddler in play.
Correct Answer: A
Rationale: The correct answer is A: Check to see if the elbow restraint is in place for an infant postoperative from a surgical correction of a cleft palate. This task should be performed first because it involves the safety and well-being of the infant. Elbow restraints are crucial post-surgery to prevent the infant from inadvertently touching or injuring the surgical site. Ensuring the elbow restraint is in place promptly is essential to prevent complications and promote healing.
The other choices are incorrect because they do not prioritize the immediate safety and well-being of a postoperative infant. Washing the hair of an adolescent, collecting a stool sample, and engaging a toddler in play are important tasks but can be done after ensuring the safety of the postoperative infant. It is crucial to prioritize tasks based on the urgency and potential impact on the client's health and safety.
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.
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?
- A. Keeping an appointment with a client
- B. Allowing a new mother to hold her stillborn infant
- C. Confirming that a client going for surgery has signed a consent form
- D. Refusing to disclose information about a client to the media
Correct Answer: A
Rationale: The correct answer is A: Keeping an appointment with a client. Fidelity in nursing ethics refers to the nurse's obligation to be faithful and keep promises made to clients. By keeping an appointment with a client, the nurse is demonstrating reliability and honoring their commitment, which is essential for building trust and maintaining the therapeutic relationship. Choices B, C, and D do not directly relate to fidelity. Allowing a mother to hold her stillborn infant (B) is an example of compassion and emotional support, confirming a client's surgery consent form (C) is related to autonomy and informed consent, and refusing to disclose client information to the media (D) is about confidentiality and privacy, not fidelity.
A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?
- A. Report the observation to the nurse caring for that client.
- B. Inform the nursing supervisor.
- C. Approach the man and ask why he is making copies.
- D. Notify hospital security.
Correct Answer: C
Rationale: The correct answer is C: Approach the man and ask why he is making copies. This is the first action the nurse should take to gather information and assess the situation. By directly addressing the man, the nurse can determine his intentions and potentially stop any unauthorized activity. Reporting to the nurse caring for the client (A) may lead to delays in addressing the issue directly. Informing the nursing supervisor (B) is important, but immediate action is needed. Notifying hospital security (D) should be done after gathering more information.
A nurse is participating in a disaster drill for a chemical spill. Which of the following actions should the nurse take first when caring for exposed clients?
- A. Administer antidotes for the chemical agent.
- B. Decontaminate clients by removing contaminated clothing.
- C. Assess clients for respiratory distress.
- D. Document the number of affected clients.
Correct Answer: B
Rationale: Decontaminating clients by removing contaminated clothing is the first step to prevent further exposure and harm, aligning with disaster response protocols for chemical spills.