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A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?
- A. Report the observation to the nurse caring for that client.
- B. Inform the nursing supervisor.
- C. Approach the man and ask why he is making copies.
- D. Notify hospital security.
Correct Answer: C
Rationale: The correct answer is C: Approach the man and ask why he is making copies. This is the first action the nurse should take to gather information and assess the situation. By directly addressing the man, the nurse can determine his intentions and potentially stop any unauthorized activity. Reporting to the nurse caring for the client (A) may lead to delays in addressing the issue directly. Informing the nursing supervisor (B) is important, but immediate action is needed. Notifying hospital security (D) should be done after gathering more information.
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A charge nurse is planning a staff meeting to address low morale on the unit. Which of the following actions should the charge nurse take to promote a positive discussion?
- A. Criticize staff members who have been vocal about their dissatisfaction.
- B. Invite staff to share ideas for improving the work environment.
- C. Schedule the meeting during a busy shift to ensure attendance.
- D. Focus solely on the unit's performance metrics.
Correct Answer: B
Rationale: Inviting staff to share ideas fosters collaboration and engagement, creating a positive environment for addressing morale issues and encouraging staff input.
A nurse is preparing to discharge a client who has a new prescription for warfarin. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the client about dietary restrictions with warfarin.
- B. Provide the client with written discharge instructions.
- C. Assist the client with packing personal belongings.
- D. Schedule a follow-up appointment for the client.
Correct Answer: C
Rationale: Assisting the client with packing personal belongings is a non-clinical task within the AP's scope of practice. Teaching, providing instructions, and scheduling appointments require nursing expertise.
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.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
- A. Ambulate an older adult client who has hypertension.
- B. Provide discharge instructions for a client who has a new skin graft.
- C. Check a blood product with another nurse prior to administration.
- D. Weigh a client who has heart failure.
- E. Perform an admission assessment on a client.
Correct Answer: A,D
Rationale: The correct tasks to assign to an assistive personnel (AP) are A and D. APs are trained to assist with basic care activities. Ambulating an older adult client with hypertension and weighing a client with heart failure are within the scope of practice for APs as they do not involve complex assessments or critical decision-making. Providing discharge instructions (B) requires specialized knowledge and education, which is beyond the scope of an AP. Checking a blood product (C) and performing an admission assessment (E) require specific training and expertise that only licensed nurses should perform.
A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.)
- A. Verify the client understands the surgical procedure.
- B. Validate the signature is authentic.
- C. Confirm that the consent is voluntary.
- D. Explain the surgical procedure to the client.
- E. Establish that the client is able to pay for the surgical procedure.
Correct Answer: A,B,C
Rationale: Correct Answer: A, B, C
Rationale:
A: Verifying the client understands the surgical procedure ensures they are informed about what will occur during surgery.
B: Validating the signature is authentic confirms the client has personally given consent, enhancing legal protection.
C: Confirming consent is voluntary ensures the client is not coerced or pressured, upholding ethical principles.
Summary:
D: Explaining the surgical procedure is important but not solely the nurse's responsibility for obtaining consent.
E: Ability to pay is not a factor in obtaining informed consent.
Overall, A, B, and C are crucial steps to ensure informed and voluntary consent.