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A power outage occurs at a hospital, and a backup generator supplying power to a telemetry unit fails. After obtaining a flashlight, what is the nurse's next best action?
- A. Call the nursing supervisor
- B. Assess the most critically ill clients
- C. Obtain oxygen tanks for clients on oxygen
- D. Delegate which clients the NA should monitor
Correct Answer: C
Rationale: Obtaining oxygen tanks is the priority, as room oxygen sources fail during a power outage, and clients on oxygen are at immediate risk.
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A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first
- A. focus on reality orientation to place and person
- B. assist with the report of the client's complaint to the police
- C. obtain more details of the client's claim of abuse
- D. document the statement on the client's chart with a report to the manager
Correct Answer: C
Rationale: Obtain more details of the client's claim of abuse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse to ensure appropriate action and protection for the client.
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
- A. has had a change in respiratory rate by an increase of 2 breaths
- B. has had a change in heart rate by an increase of 10 beats
- C. was minimally responsive to voice and touch
- D. has had a blood pressure change by a drop in 8 mmHg systolic
Correct Answer: C
Rationale: A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations.
A client states, 'People think I'm no good, you know what I mean?' Which of these responses would be most therapeutic?
- A. Well people often take their own feelings of inadequacy out on others.'
- B. I think you're good. So you see, there's one person who likes you.'
- C. I'm not sure what you mean. Tell me a bit more about that.'
- D. Let's discuss this to see the reasons you create this impression on people.'
Correct Answer: C
Rationale: I'm not sure what you mean. Tell me a bit more about that.' This therapeutic communication technique elicits more information, especially when delivered in an open, non-judgmental fashion.
The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?
- A. Focus on the child's needs and recovery
- B. Explain the cause of the child's illness
- C. Acknowledge that early care would have been better
- D. Accept their feelings without judgment
Correct Answer: D
Rationale: Accept their feelings without judgment. Parents often blame themselves for their child's illness. Feeling helpless and angry is normal and these feelings must be accepted.
An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
- A. How long have you been a UAP and what units you have worked on?
- B. What type of care do you give on the surgical unit and what ages of clients?
- C. What is your comfort level in caring for children and at what ages?
- D. Have you reviewed the list of expected skills you might need on this unit?
Correct Answer: D
Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.