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A nurse is triaging clients in the emergency department after a multi-vehicle accident. Which of the following clients should the nurse prioritize for immediate care?
- A. A client with a laceration on the arm and stable vital signs.
- B. A client with a closed fracture of the femur and severe pain.
- C. A client with chest pain and shortness of breath.
- D. A client with abrasions on the face and neck.
Correct Answer: C
Rationale: The correct answer is C: A client with chest pain and shortness of breath. This client should be prioritized for immediate care as chest pain and shortness of breath can indicate a potentially life-threatening condition such as a heart attack or pulmonary embolism. The nurse should assess and intervene promptly to prevent further complications.
Choice A is incorrect because a laceration on the arm with stable vital signs is not immediately life-threatening. Choice B, a closed fracture of the femur with severe pain, while painful, does not pose an immediate threat to life. Choice D, abrasions on the face and neck, are not considered priority over potential cardiac or respiratory issues.
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A nurse manager is reviewing the unit's compliance with infection control protocols. Which of the following findings requires immediate intervention?
- A. An assistive personnel wears gloves while feeding a client.
- B. A nurse uses hand sanitizer before entering a client's room.
- C. A nurse reuses a disposable gown after leaving a client's room.
- D. A client's visitor washes their hands upon entering the room.
Correct Answer: C
Rationale: Reusing a disposable gown violates infection control protocols, as it risks cross-contamination. The other actions align with or exceed standard infection control practices.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse prioritize?
- A. Place the client in a high-Fowler's position.
- B. Insert a tongue depressor to prevent tongue biting.
- C. Protect the client from injury by clearing the area.
- D. Administer a prescribed anticonvulsant immediately.
Correct Answer: C
Rationale: Protecting the client from injury by clearing the area is the priority to ensure safety during a seizure. Positioning, tongue depressors, and medication administration are secondary or contraindicated.
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.
An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating?
- A. Agency policies for the LPN
- B. The documented experience level of the LPN
- C. The documented skill level of the LPN
- D. State Nurse Practice Act for the LPN
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Act for the LPN. This is the priority criterion because the Nurse Practice Act outlines the scope of practice for LPNs in a specific state, ensuring that the tasks delegated are within their legal scope. This helps to protect patient safety and ensures legal compliance.
A: Agency policies for the LPN - Agency policies are important but do not take precedence over legal requirements outlined in the Nurse Practice Act.
B: The documented experience level of the LPN - Experience level is important but does not guarantee legal authority to perform certain tasks.
C: The documented skill level of the LPN - Skill level is important but does not override legal limitations set by the Nurse Practice Act.
A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?
- A. Assigning the most competent RN to perform a central line dressing change
- B. Assigning the most efficient AP to perform glucometer monitoring for each client
- C. Assigning two assistive personnel (AP) to ambulate all clients
- D. Assigning a new graduate nurse to perform a wet-to-dry dressing change
Correct Answer: D
Rationale: Correct Answer: D - Assigning a new graduate nurse to perform a wet-to-dry dressing change.
Rationale:
1. Wet-to-dry dressing changes require advanced skill and knowledge.
2. New graduate nurses may not have sufficient experience to perform this task safely.
3. Risk of complications such as infection or tissue damage is higher with inexperienced staff.
Summary of Other Choices:
A: Assigning the most competent RN to perform a central line dressing change - Competent RNs are appropriate for this task.
B: Assigning the most efficient AP to perform glucometer monitoring - Routine task suitable for AP.
C: Assigning two AP to ambulate all clients - Ensures safety and efficiency in patient care.