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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.
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A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
- A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
- B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
- C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
- D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
Correct Answer: C
Rationale: The correct answer is C because administering medication without the client's knowledge and against their refusal constitutes a breach of the duty of care and violates the client's autonomy and right to make decisions about their own treatment. This is an example of negligence as it goes against the ethical principle of informed consent. Choices A, B, and D do not meet the criteria for negligence as they involve actions taken in the best interest of the client, such as preventing harm or reporting concerning findings to the provider. In choice A, the nurse is trying to prevent harm by applying restraints to a client who is making a potentially harmful decision. In choice B, the nurse is identifying and reporting a concerning clinical finding promptly. In choice D, the nurse is attempting to educate the client and prevent harm related to dietary restrictions.
A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- A. Blood for PaCO2
- B. Random stool specimen
- C. Wound drainage for culture
- D. Urine from an indwelling catheter
Correct Answer: B
Rationale: The correct answer is B: Random stool specimen. The rationale is that collecting a random stool specimen does not require specialized training or skills, making it appropriate for assistive personnel (AP) to perform. Collecting blood for PaCO2 (A) requires specific training and knowledge of arterial blood gas sampling. Wound drainage for culture (C) involves sterile technique and knowledge of wound care. Urine from an indwelling catheter (D) requires knowledge of catheter care and sterile technique. Therefore, delegating the collection of a random stool specimen to AP is the most appropriate choice.
A charge nurse plans to use effective change strategies when implementing a change in a nursing procedure on the medical-surgical unit. Which of the following actions should the charge nurse take during the moving stage of change?
- A. Set a target date.
- B. Use tactics to alert staff nurses that a change is needed.
- C. Evaluate the effectiveness of the change.
- D. Assess the problem.
Correct Answer: A
Rationale: The correct answer is A: Set a target date. During the moving stage of change, setting a target date is crucial to create a sense of urgency and maintain momentum. It provides a clear timeline for implementation, ensuring accountability and focus. This action helps prevent delays and keeps the change process on track.
Choice B is incorrect because alerting staff nurses about the need for change is more relevant during the unfreezing stage. Choice C is incorrect as evaluating effectiveness typically occurs during the refreezing stage. Choice D is incorrect as assessing the problem is part of the initial stages of change management, not the moving stage.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
- A. A middle adult male who is diaphoretic and reports epigastric pain
- B. A toddler who has a laceration on his forehead and is screaming
- C. An adolescent female client who is belligerent and has slurred speech
- D. A young adult with a painful sunburn of his face and arms
Correct Answer: A
Rationale: The correct answer is A. The nurse should have the provider care for the middle adult male who is diaphoretic and reports epigastric pain immediately. Diaphoresis and epigastric pain can be signs of a heart attack or other serious cardiac issue, requiring urgent medical attention to prevent complications. The other choices do not present an immediate life-threatening situation. The toddler with a laceration can be addressed after stabilizing the critical client. The belligerent adolescent may need behavioral intervention but does not require immediate medical attention. The young adult with sunburn, while painful, is not a life-threatening condition that requires immediate provider care.
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.