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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.
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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.
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.
A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?
- A. Monitor for impending signs of shock.
- B. Initiate enteric precaution procedures.
- C. Reduce light, noise and temperature.
- D. Encourage electrolyte supplements.
Correct Answer: A
Rationale: Monitoring for signs of shock is critical due to the client's dehydration and fluid volume deficit, which could lead to organ failure. Enteric precautions, environmental adjustments, and electrolyte supplements are important but secondary to preventing life-threatening shock.
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.
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.