Nokea
A nurse manager is reviewing incident reports from the past month. Which of the following situations should the nurse prioritize for follow-up?
- A. A client received a meal tray with the wrong diet.
- B. An assistive personnel failed to report a client's low blood glucose level.
- C. A nurse documented a medication administration 30 minutes late.
- D. A client's call light was answered after a 10-minute delay.
Correct Answer: B
Rationale: The correct answer is B. Prioritizing follow-up on the assistive personnel's failure to report a client's low blood glucose level is crucial as it directly impacts patient safety and could lead to serious consequences. Not reporting a critical health issue promptly can result in harm or even death. Addressing this issue promptly is essential to prevent recurrence and ensure the well-being of the patient. Choices A, C, and D involve errors or delays that are concerning but do not pose an immediate threat to patient safety compared to the failure to report a critical health issue.
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A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process?
- A. Discovery phase
- B. Decision phase
- C. Trial phase
- D. Complaint phase
Correct Answer: A
Rationale: The correct answer is A: Discovery phase. During the discovery phase of a legal process, both parties exchange information and evidence relevant to the case. A deposition is a part of the discovery phase where witnesses are questioned under oath. In this scenario, the nurse manager would be required to participate in a deposition to provide information related to the lawsuit.
Option B: Decision phase is incorrect as it typically refers to the phase where a judgment or verdict is made. Option C: Trial phase is incorrect as it involves the actual court proceedings. Option D: Complaint phase is incorrect as it is the initial phase where a formal complaint is filed to initiate the legal process.
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 nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
- A. A client who has Guillain-Barre syndrome
- B. A client who has a lumbosacral spinal tumor
- C. A client who has systemic sclerosis
- D. A client who has amyotrophic lateral sclerosis (ALS)
Correct Answer: B
Rationale: The correct answer is B. A client with a lumbosacral spinal tumor may need assistance with meals due to potential mobility limitations or weakness. The nurse can delegate this task to the AP as it falls within their scope of practice. Clients with Guillain-Barre syndrome (choice A) may have muscle weakness and difficulty swallowing, requiring skilled nursing assessment during mealtime. Clients with systemic sclerosis (choice C) may have gastrointestinal involvement, necessitating careful monitoring during meals. Clients with ALS (choice D) have progressive muscle weakness, making it crucial for a nurse to assess their ability to eat safely. Delegating meal assistance for these clients to an AP may compromise their safety.
A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?
- A. Determine the social skills of the AP.
- B. Assess the AP's ability to follow the client's teaching plan.
- C. Provide a clear description of the task to the AP.
- D. Evaluate the ability of the AP to work with peers.
Correct Answer: C
Rationale: The correct answer is C: Provide a clear description of the task to the AP. This is essential in delegation to ensure the AP understands what is expected. Determining social skills (A) and evaluating ability to work with peers (D) are not directly related to task delegation. Assessing ability to follow a teaching plan (B) is important but not the primary focus in task delegation.
A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
- A. WBC 6,000/mm3
- B. BUN 15 mg/dL
- C. Hemoglobin 14 g/dL
- D. Platelet count 60,000/mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet count 60,000/mm3. A low platelet count (thrombocytopenia) can increase the risk of bleeding during surgery. Normal platelet count is around 150,000-450,000/mm3. The other options are within normal ranges: A) WBC 6,000/mm3 is normal, B) BUN 15 mg/dL is normal, and C) Hemoglobin 14 g/dL is normal. Therefore, the nurse should follow up on the platelet count to ensure the client's safety during surgery.