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An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100°F (37.8°C), blood pressure 98/50 mm Hg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Replace fluids intravenously based on intake and output.
- B. Record the amount of daily wound drainage.
- C. Assess skin condition and turgor for breakdown.
- D. Turn every 2 hours around the clock from side-to-side.
Correct Answer: A
Rationale: IV fluid replacement addresses hypovolemia and prevents shock, critical given the client's vital signs. Recording drainage, assessing skin, and turning are important but secondary to stabilizing fluid status.
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To help prevent by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will
- A. demonstrate how to complete an adverse occurrence or variance report.
- B. discuss how to handle complaints from clients and/or their families.
- C. describe how to obtain legal services if needed.
- D. maintain personal malpractice insurance.
Correct Answer: B
Rationale: Teaching nurses to handle complaints effectively can prevent escalation to litigation by resolving conflicts early. Completing variance reports, obtaining legal services, or maintaining insurance are important but less preventive than addressing complaints directly.
The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse manager?
- A. Contact the healthcare provider to ensure that a prescription for restraints was written.
- B. Advise the staff nurse to remove the restraints from the client's wrists.
- C. Close the door to the room to avoid disturbing other clients in nearby rooms.
- D. Determine if the client has an as needed (PRN) prescription for an antianxiety agent
Correct Answer: B
Rationale: Removing restraints is the priority as they are unjustified for staff convenience and violate client rights. Checking for a prescription, closing the door, or considering antianxiety medication do not address the immediate ethical and safety concerns.
The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
- A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
- B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
- C. Renal transplant yesterday, complaining of flank pain and who states, 'it's hot in here.'
- D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
- B. Heparin in Normal Saline prescribed for deep vein thrombosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Regular insulin in Normal Saline prescribed for ketoacidosis.
Correct Answer: A
Rationale: Ceftriaxone can be safely administered by gravity infusion with nurse monitoring, as its dosing is less sensitive to minor flow rate variations. Heparin, magnesium, and insulin require precise infusion rates due to risks of bleeding, toxicity, or glucose imbalances, necessitating an IV pump.
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?
- A. Begin initial sterile wound care for surgical clients.
- B. Validate prescribed intravenous flow rates.
- C. Determine the need for urinary catheterizations.
- D. Receive a postoperative client and conduct the assessment.
Correct Answer: B
Rationale: Validating IV flow rates is within the PN's scope, involving routine checks of orders and drip rates. Initial wound care, assessing catheter need, and postoperative assessments require RN clinical judgment.