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After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range: International Normalized Ratio [0.8 to 1.1], Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)], Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)], Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]
- A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).
- B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.
- C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).
- D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).
Correct Answer: A
Rationale: A BNP of 1000 pg/mL indicates severe heart failure, requiring urgent interventions like oxygen and diuretics. The INR is therapeutic, glucose is mildly elevated, and potassium is normal, making these less urgent.
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A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?
- A. Caution the nurse that one more tardiness will result in probational employment.
- B. Offer to switch the nurse's shift assignments to afternoons or evenings.
- C. Stress the expectation that the nurse will arrive on time for all scheduled shifts.
- D. Have the nurse sign a copy of the hospital employee attendance policy.
Correct Answer: C
Rationale: Stressing punctuality expectations communicates the importance of timeliness clearly and respectfully. Threatening probation is overly punitive, changing shifts may not solve the issue, and signing a policy is less effective than direct communication.
An experienced, female practical nurse (PN) is hired to work on the surgical unit of a tertiary hospital. The first day she is working on the unit, the PN tells the charge nurse that she has excellent wound care skills. It is a busy day and a postoperative client needs to have a sterile dressing change. Which action is best for the charge nurse to take?
- A. Review the PN's skill checklist to assess for wound care competency.
- B. Watch the PN perform sterile wound care to validate her skill level.
- C. Tell the PN that past experience does not indicate ability to perform skills.
- D. Ask the PN to change the sterile dressing while the nurse is busy.
Correct Answer: B
Rationale: Observing the PN perform wound care ensures her skills meet standards, protecting client safety. Reviewing a checklist, dismissing experience, or delegating without verification are less effective.
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.
It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?
- A. One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain.
- B. Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute.
- C. After ambulating, a postoperative client grimaces and reports incisional pain at a '9 on a ten-point scale'.
- D. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced.
Correct Answer: C
Rationale: The postoperative client with severe pain requires immediate RN assessment and intervention due to potential complications. The other clients' needs (PRN medication, stable vitals, routine patch replacement) can be managed by a PN under supervision.
Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?
- A. Announce the new plan at a special employee wellness event.
- B. Determine staff opinion of current healthcare insurance costs.
- C. Survey the nurses to see who wants to keep the old benefits plan.
- D. Be available to all shifts to discuss the changes in health benefits.
Correct Answer: D
Rationale: Being available to discuss changes ensures clear communication and addresses concerns across all shifts, fostering acceptance. Announcing at an event, assessing current costs, or surveying preferences are less critical post-approval.