Nokea
Following a six-week refresher course, a female nurse who has been out of the workforce for 10 years is assigned to a medical unit for orientation. After the first week of orientation, the charge nurse notes that the orientee is overwhelmed by her daily assignments, which are less than one-half the assignments of the regular staff, and the assignments are incomplete at the end of each day. The following week, which action is best for the charge nurse to take?
- A. Wait until the end of the second week to see if the orientee is able to complete her assignments.
- B. Assign the orientee to work with an experienced nurse who is a long-time, efficient employee.
- C. Inform the supervisor that for client safety this nurse should be assigned to a slower-paced unit.
- D. Talk to the orientee and ask her if she has considered working in a less stressful environment.
Correct Answer: B
Rationale: Pairing with an experienced nurse provides mentorship, enhancing skills and confidence. Waiting, transferring, or suggesting a less stressful environment may delay support or undermine the orientee's potential.
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The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?
- A. Administered two medications to the same client at the wrong time.
- B. Documented data in the clinical record before assessing client's condition.
- C. Served a diet tray to a client who was NPO for a scheduled procedure.
- D. Changed work assignments without prior approval from charge nurse.
Correct Answer: B
Rationale: Falsifying documentation by recording data before assessment is a serious ethical breach, warranting PRC review. Medication errors, serving a tray, or changing assignments are less severe and can be addressed through counseling.
The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
- A. A client who had an abdominal-perineal resection 3 days ago has no drainage on the dressing and is reporting chills.
- B. A client who fell from a ladder and has a collapsed left lower lung with 100 mL drainage in a chest tube collection container.
- C. A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm-sized dark red drainage.
- D. A client who is post-mastectomy 2 days ago and has 50 mL of serosanguineous fluid in a Jackson-Pratt drain.
Correct Answer: A
Rationale: The client with no drainage and chills may have an infection or sepsis, which are life-threatening complications requiring immediate assessment and physician notification. The chest tube drainage is normal, the gunshot wound drainage is not excessive, and the mastectomy drain output is expected, making these less urgent.
A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)
- A. Identify locations of skin lesions on a newly admitted client.
- B. Empty the ostomy bag for a client with a temporary colostomy.
- C. Provide a complete bed bath for a comatose client.
- D. Perform foot care including toenail trimming and heel care.
- E. Give mouth care to an elderly client who has a tracheostomy.
Correct Answer: B,C
Rationale: Emptying an ostomy bag and providing a bed bath are routine tasks within the UAP's scope. Identifying lesions, performing foot care, and giving tracheostomy mouth care require clinical judgment and are RN tasks.
A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?
- A. Can the equipment be updated each year?
- B. How many departments can use this equipment?
- C. Is the cost of equipment reasonable?
- D. Will the equipment require annual repair?
Correct Answer: B
Rationale: The number of departments using the equipment maximizes its benefit and cost-effectiveness across the organization. Updates, cost, and repairs are important but secondary to the equipment's overall utility.
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.