Nokea
A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include?
- A. Place dry towels at the base of doors.
- B. Move client care equipment into the hallway.
- C. Close the windows in client rooms.
- D. Use the fire extinguisher by aiming at the top of the flames.
Correct Answer: C
Rationale: The correct answer is C: Close the windows in client rooms. Closing windows can help prevent the spread of fire by limiting oxygen supply. This action can help contain the fire within the unit and prevent it from escalating. Placing dry towels at door bases (choice A) can be dangerous as they can catch fire. Moving client care equipment into the hallway (choice B) can obstruct evacuation routes. Using a fire extinguisher by aiming at the top of flames (choice D) is incorrect as the base of the fire should be targeted to extinguish it effectively.
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A nurse is caring for a client who is having difficulty walking following a stroke. For which of the following members of the interprofessional team should the nurse request a referral?
- A. Occupational therapist
- B. Social worker
- C. Dietitian
- D. Physical therapist
Correct Answer: D
Rationale: The correct answer is D: Physical therapist. The physical therapist specializes in helping individuals regain mobility and strength after a stroke, making them the most appropriate professional to address the client's difficulty walking. They will develop a personalized exercise program to improve balance and coordination. Referring to the other options would not directly address the client's physical mobility issues. Occupational therapists focus on daily living activities, social workers on emotional and social support, and dietitians on nutritional needs, none of which directly address the client's walking difficulty.
A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?
- A. The emergency department nurse is waiting to give report on a new admission.
- B. Two staff members have called to say they will be absent.
- C. A nurse on the previous shift wrote an incident report about a medication error.
- D. Transport assistance is unavailable to take a client to occupational therapy.
Correct Answer: A
Rationale: The correct answer is A because the charge nurse should address urgent situations first. The emergency department nurse waiting to give report on a new admission indicates a critical patient needing immediate attention. Addressing this first ensures timely and appropriate care for the patient. Choices B and D, staff absences and transport assistance availability, can be managed after addressing the urgent patient situation. Choice C, the incident report about a medication error, is important but not as time-sensitive as the new admission report. Therefore, the charge nurse should prioritize addressing the emergency department nurse's report first.
A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?
- A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
- B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38° C (101° F)
- C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void
- D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy
Correct Answer: A
Rationale: An absent pedal pulse indicates a critical circulatory issue, potentially limb-threatening, requiring immediate attention over other less urgent conditions.
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
- A. Assess the staff nurses' knowledge deficit.
- B. Demonstrate use of the pump during medication administration.
- C. Plan an in-service education program on the unit.
- D. Pair an inexperienced nurse with an experienced nurse.
Correct Answer: A
Rationale: The correct answer is A: Assess the staff nurses' knowledge deficit. This is the priority action because it helps identify the root cause of the difficulty with the new IV infusion pumps. By assessing the staff nurses' knowledge deficit, the charge nurse can determine if additional training, education, or support is needed. This step is crucial in addressing the problem effectively and ensuring safe medication administration.
Other choices:
B: Demonstrating the use of the pump during medication administration may be helpful but should come after assessing the knowledge deficit.
C: Planning an in-service education program is important but should be based on the assessment of the staff nurses' knowledge deficit.
D: Pairing an inexperienced nurse with an experienced nurse may be beneficial but does not directly address the underlying issue of knowledge deficit.