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During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe an as needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. Which instruction should the nurse provide the unit clerk?
- A. Remain with this client and monitor the vital signs while the nurse takes the call.
- B. Ask the healthcare provider to remain on 'hold' until the nurse can confirm the prescription.
- C. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.
- D. Tell the healthcare provider the nurse will return the phone call as soon as possible.
Correct Answer: D
Rationale: The unit clerk cannot take verbal orders; instructing the provider to be called back ensures the nurse handles the prescription directly. Monitoring vitals, holding the call, or writing orders are inappropriate for the clerk's role.
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The nurse manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse manager respond?
- A. Choose to send another nurse who is more receptive because the older nurse is not interested.
- B. Ask the nurse why she thinks there is no need for an in-service program about these emergencies.
- C. Inform the older nurse that in-service is not optional and her scheduled attendance is mandatory.
- D. Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.
Correct Answer: D
Rationale: Encouraging the nurse to share concerns fosters collaboration and addresses barriers to participation, enhancing engagement. Sending another nurse, questioning her views confrontationally, or mandating attendance may create resentment or fail to address her concerns effectively.
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.
A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
- A. Let each family member ask a question one at a time.
- B. Request the healthcare provider to speak with the family.
- C. Ask the family to identify a specific spokesperson.
- D. Page a chaplain on call to be present for questions.
Correct Answer: C
Rationale: Designating a spokesperson streamlines communication, reducing repetitive questions and respecting client privacy. Individual questioning, provider involvement, or chaplain support are less immediate solutions.
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.
When triaging emergency room clients, which client should the nurse assess first?
- A. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
- B. A female client with severe right lower abdominal pain who is febrile and vomiting.
- C. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.
- D. A child who has had a cold for two days and now is coughing up green sputum.
Correct Answer: B
Rationale: Severe right lower abdominal pain with fever and vomiting suggests appendicitis, a surgical emergency requiring immediate assessment. Vomiting, leg pain, and green sputum are less urgent conditions.