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A nurse manager along with members of the nurse practice committee are conducting a skills day for assistive personnel in the medical surgical unit to validate competency. Which skills demonstrated by assistive personnel require immediate follow-up. Select the '3' findings that require immediate follow-up.
- A. AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping.
- B. AP 2-Verifies with nurse the order in which protective equipment should be removed.
- C. AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room.
- D. AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing.
- E. AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit.
- F. AP 4-Successfully completed skills of simulation including emptying the client's trash can
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Option A requires follow-up because pulling the fire alarm before removing the client may result in leaving the client in a dangerous situation. Option D needs follow-up because not washing hands after assisting a client into bed can lead to the spread of infection. Option E warrants follow-up as not knowing the alarm locations could delay response to emergencies. Options B, C, and F are not immediate concerns as they demonstrate proper procedures or successful completion of tasks.
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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 pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula
- B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions
- C. A school-age child who has diabetes mellitus and requires blood glucose monitoring
- D. A toddler who has both arms in casts and needs to be fed his breakfast
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause severe respiratory distress. Assessing the infant's respiratory status is crucial as pertussis can lead to respiratory failure. Oxygen therapy is essential for maintaining adequate oxygenation levels. The nurse must monitor the infant's respiratory rate, effort, and oxygen saturation levels to ensure proper oxygenation. This assessment takes priority over the other clients' needs.
Choice B is incorrect because although the adolescent has sickle cell crisis, they are stable and ready for discharge instructions, which can be addressed after the critical assessment of the infant is completed.
Choice C is incorrect as monitoring blood glucose levels in a child with diabetes is important but does not take precedence over assessing a critically ill infant with pertussis.
Choice D is incorrect as feeding a toddler with both arms in casts can be challenging but does not pose an immediate threat to their health compared to the infant with pertussis requiring oxygen.
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A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
- A. Transporting a school-age client who is in traction to another department
- B. Reading a book to a preschool client who has AIDS
- C. Rocking an infant who was admitted for croup
- D. Playing a computer video game with an adolescent who has sickle cell disease
Correct Answer: A
Rationale: The correct answer is A because transporting a school-age client in traction requires specialized training to ensure proper handling and safety precautions. Traction devices are delicate and any mishandling could lead to injury. Reading a book to a preschool client with AIDS (B) promotes emotional support. Rocking an infant with croup (C) provides comfort. Playing a computer video game with an adolescent with sickle cell disease (D) promotes social interaction and distracts from pain.
A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A. A client who has a small circular partial-thickness burn of the left calf
- B. A client who has a massive head injury and is experiencing seizures
- C. A client who has a splinted open fracture of left medial malleolus
- D. A client who has severe respiratory stridor and a deviated trachea
Correct Answer: D
Rationale: The correct answer is D: A client who has severe respiratory stridor and a deviated trachea. This client should be assessed first because stridor indicates airway obstruction, which can rapidly progress to respiratory failure. A deviated trachea suggests a possible tension pneumothorax, a life-threatening condition requiring immediate intervention to prevent further deterioration. Assessing and managing the airway takes priority over other injuries.
Incorrect choices:
A: A small circular partial-thickness burn of the left calf is a lower priority as it does not pose an immediate threat to life compared to airway compromise.
B: A massive head injury with seizures is serious but managing the airway is the priority in this scenario.
C: A splinted open fracture of the left medial malleolus is important but does not pose an immediate threat to life compared to airway and breathing concerns.
A nurse is caring for a client who is experiencing chest pain. Which of the following actions should the nurse take first?
- A. Administer prescribed nitroglycerin.
- B. Obtain a 12-lead ECG.
- C. Notify the provider of the chest pain.
- D. Assess the client's pain characteristics.
Correct Answer: D
Rationale: Assessing the client's pain characteristics provides critical data to guide further actions, such as medication administration or diagnostic testing, and is the first step in managing chest pain.