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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.
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A nurse is caring for a client who is postoperative and has a chest tube. The nurse notes that the chest tube is disconnected from the drainage system. Which of the following actions should the nurse take first?
- A. Reconnect the chest tube to the drainage system.
- B. Clamp the chest tube near the insertion site.
- C. Notify the provider of the disconnection.
- D. Place the end of the chest tube in sterile water.
Correct Answer: D
Rationale: Placing the end of the chest tube in sterile water prevents air from entering the pleural space, which could cause a pneumothorax, making it the priority action.
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?
- A. Keeping an appointment with a client
- B. Allowing a new mother to hold her stillborn infant
- C. Confirming that a client going for surgery has signed a consent form
- D. Refusing to disclose information about a client to the media
Correct Answer: A
Rationale: The correct answer is A: Keeping an appointment with a client. Fidelity in nursing ethics refers to the nurse's obligation to be faithful and keep promises made to clients. By keeping an appointment with a client, the nurse is demonstrating reliability and honoring their commitment, which is essential for building trust and maintaining the therapeutic relationship. Choices B, C, and D do not directly relate to fidelity. Allowing a mother to hold her stillborn infant (B) is an example of compassion and emotional support, confirming a client's surgery consent form (C) is related to autonomy and informed consent, and refusing to disclose client information to the media (D) is about confidentiality and privacy, not fidelity.
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.
A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?
- A. The physiologic status of the clients on the unit
- B. Social relationships between nurses working the oncoming shift
- C. Personal comfort level in making the assignments
- D. The most experienced nurse receives the more complex clients
Correct Answer: A
Rationale: The correct answer is A. The charge nurse should consider the physiologic status of the clients on the unit when making assignments to ensure that each client receives appropriate care based on their health condition. This factor is crucial for patient safety and outcomes. Choice B is incorrect as social relationships between nurses should not influence patient assignments. Choice C is incorrect as personal comfort level should not drive assignment decisions, rather patient needs should. Choice D is incorrect as assigning more complex clients based solely on experience may not always be the best approach, as other factors like workload and skill mix should also be considered.
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.