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A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?
- A. A client who has a closed femur fracture from a fall
- B. A client who has a superficial burn covering 10% of their total body surface area
- C. A client who is experiencing severe vomiting and diarrhea with tachycardia
- D. A client who is confused and has slurred speech
Correct Answer: D
Rationale: Confusion and slurred speech suggest a possible stroke, a time-sensitive emergency requiring immediate assessment to optimize outcomes.
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A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?
- A. Notify the client's provider about the incident.
- B. Instruct the AP to discontinue the conversation.
- C. Complete an incident report about the breach of client confidentiality.
- D. Reassign the AP to other clients on the unit.
Correct Answer: B
Rationale: The correct answer is B: Instruct the AP to discontinue the conversation. The nurse should address the situation immediately by instructing the AP to stop discussing the client's care in a public setting like the cafeteria to maintain client confidentiality. This action prevents further breach of confidentiality and reinforces the importance of respecting privacy. Notifying the provider (A) may be necessary later, but the immediate action should be to stop the conversation. Completing an incident report (C) is important for documentation but is not the first step. Reassigning the AP (D) may not address the root issue of confidentiality breach.
A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?
- A. Request the client sign an informed consent.
- B. Encourage the client to reconsider their decision
- C. Communicate the client's decision to the provider.
- D. Provide care for the client using a sympathetic approach.
Correct Answer: C
Rationale: The correct answer is C: Communicate the client's decision to the provider. This is the most appropriate action as it ensures the client's wishes are respected while also involving the healthcare provider in the decision-making process. By communicating the client's decision, the nurse is upholding the client's autonomy and promoting patient-centered care. Option A is incorrect as the client's refusal of chemotherapy does not require informed consent. Option B is inappropriate as it undermines the client's autonomy by pressuring them to reconsider. Option D is not the best choice as it focuses on the nurse's approach rather than facilitating communication between the client and the provider.
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
- A. Determine the reasons the nurses are not taking scheduled breaks.
- B. Provide coverage for the nurses' breaks.
- C. Review facility policies for taking scheduled breaks.
- D. Discuss time management strategies with the nurses.
Correct Answer: A
Rationale: Determining the reasons for not taking breaks identifies the root cause, enabling targeted solutions to ensure staff well-being.
A nurse is teaching a class of newly licensed nurses about evidence-based practice. The nurse should include which of the following as the first step in evidence-based practice?
- A. Develop a clinical question.
- B. Collect evidence from a variety of sources.
- C. Apply research to client care practice.
- D. Critically assess the evidence.
Correct Answer: A
Rationale: The correct answer is A: Develop a clinical question. This is the first step in evidence-based practice as it helps focus the search for evidence. By formulating a clear and specific question, nurses can identify relevant research studies to inform their practice. Collecting evidence (B) comes after formulating the question. Applying research to practice (C) and critically assessing evidence (D) are important steps but occur later in the process.
A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?
- A. A client who has gestational diabetes and is receiving biweekly nonstress tests
- B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
- C. A client who is at 32 weeks of gestation and has premature rupture of membranes
- D. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
Correct Answer: D
Rationale: The correct answer is D because the RN from a medical-surgical unit would have experience managing postoperative care and understanding the complexities of a patient with a PCA pump. Choice A involves monitoring nonstress tests which are more routine and can be handled by other staff. Choice B requires specific knowledge of preeclampsia and labor induction medications. Choice C involves managing premature rupture of membranes which requires obstetrical expertise. Overall, choice D is the most appropriate for the RN who has floated from a medical-surgical unit due to their experience with postoperative care and pain management.