Nokea
A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
- A. Evaluate the results.
- B. Brainstorm solutions.
- C. Implement a resolution.
- D. Identify the problem
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first step in conflict resolution as it allows the nurse manager to understand the root cause of the conflict between pharmacy and staff nurses. By identifying the problem, the nurse manager can gather relevant information, perspectives, and concerns from both parties. This step is crucial in developing an effective resolution strategy.
Choice A (Evaluate the results) is incorrect as evaluation should come after identifying the problem. Choice B (Brainstorm solutions) is premature without understanding the underlying issue. Choice C (Implement a resolution) should not be done before identifying the problem to ensure the solution addresses the actual conflict.
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A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
- A. Respite care
- B. Restorative care
- C. Hospice care
- D. Mental health care
Correct Answer: A
Rationale: The correct answer is A: Respite care. This is the most appropriate referral for the client's partner who needs time off from caregiving responsibilities to complete errands. Respite care provides temporary relief for the primary caregiver, allowing them to take a break while ensuring the client's needs are still met. This helps prevent caregiver burnout and promotes overall well-being for both the caregiver and the client.
Choices B, C, and D are incorrect:
B: Restorative care focuses on restoring the client's functional abilities and independence, which is not directly related to the partner's need for time off.
C: Hospice care is for clients with terminal illnesses who are no longer receiving curative treatment, which is not applicable in this scenario.
D: Mental health care may be beneficial for the client or caregiver in managing emotions and stress, but it does not address the immediate need for respite care.
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
- A. Reinforce discharge teaching to clients.
- B. Focus on providing care that prevents life-threatening emergencies.
- C. Stock additional unit supplies.
- D. Instruct the assistive personnel (AP) to focus on clients' ADLs.
Correct Answer: B
Rationale: Correct Answer: B - Focus on providing care that prevents life-threatening emergencies.
Rationale: During a disaster, the nurse's priority is to ensure the safety and well-being of clients by focusing on providing care that prevents life-threatening emergencies. By prioritizing care to prevent life-threatening situations, the nurse can help maintain the stability and health of clients during the crisis. This action aligns with disaster protocols and ensures that resources are utilized effectively to address the most critical needs first.
Incorrect Choices:
A: Reinforcing discharge teaching is not a priority during a disaster when immediate life-saving interventions are needed.
C: Stocking additional supplies may be important, but it is not the immediate priority when working with limited staff during a severe storm.
D: Instructing assistive personnel to focus on clients' ADLs may not address the urgency of preventing life-threatening emergencies during a disaster.
A nurse is delegating tasks to an assistive personnel (AP) for a client with a pressure injury. Which of the following tasks is appropriate for the AP to perform?
- A. Assess the stage of the pressure injury.
- B. Reposition the client every 2 hours.
- C. Apply a prescribed wound dressing.
- D. Evaluate the client's skin integrity.
Correct Answer: B
Rationale: Repositioning the client every 2 hours is a routine task that helps prevent further skin breakdown and is within the AP's scope of practice. Assessment, dressing application, and evaluation require nursing judgment.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Monitor the client's vital signs every 4 hours.
- B. Administer a prescribed benzodiazepine.
- C. Assess the client for tremors or agitation.
- D. Provide the client with a quiet environment.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a quiet environment. This task can be delegated to an assistive personnel (AP) because it involves creating a suitable environment for the client, which does not require specialized nursing skills. Assisting the client in a quiet environment can help minimize triggers and promote calmness during alcohol withdrawal.
A: Monitoring vital signs every 4 hours requires nursing judgment to interpret the results and decide on appropriate interventions.
B: Administering a benzodiazepine is a medication administration task that should be done by a nurse who can assess the client's condition and response to the medication.
C: Assessing the client for tremors or agitation involves clinical judgment and requires a nurse's expertise to determine the appropriate interventions.
In summary, providing a quiet environment is a task that can be safely delegated to an assistive personnel, while the other options involve assessments, medication administration, and clinical judgment that are within the scope of nursing practice.
A nurse is conducting a performance evaluation for an assistive personnel (AP). Which of the following actions by the AP should the nurse identify as requiring further training?
- A. The AP checks a client's identification band before providing a meal tray.
- B. The AP reports a client's complaint of pain to the nurse immediately.
- C. The AP uses an alcohol-based hand rub after assisting a client with ambulation.
- D. The AP leaves a client's bed in the lowest position without raising side rails for a client at risk for falls.
Correct Answer: D
Rationale: The correct answer is D. Leaving a client's bed in the lowest position without raising side rails for a client at risk for falls is a safety violation. The nurse should identify this action for further training because it puts the client at risk of injury. Lowering the bed and raising side rails are essential fall prevention measures. Checking the client's identification band (A) ensures correct client identification. Reporting client complaints of pain (B) promptly is important for timely intervention. Using hand rub after assisting a client (C) promotes infection control. Options E, F, and G are not provided in the question. In summary, choice D is correct as it pertains to client safety, while the other options demonstrate appropriate nursing actions.