Nokea
Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?
- A. Nurse Christine should offer to give medications to Nurse Ann's other two clients.
- B. Nurse Christine should inform their supervisor that assignments may need to be changed.
- C. Nurse Christine should ask other nurses who might be able to help Nurse Ann.
- D. Nurse Ann should try not to burden other nurses and continue caring for her assigned clients.
Correct Answer: B
Rationale: In this situation, when Nurse Ann informs Nurse Christine that a client's status is declining and she needs to attend to them, the most appropriate action for Nurse Christine is to inform their supervisor that assignments may need to be changed. By informing the supervisor, necessary adjustments can be made to ensure proper care for all clients. Offering to give medications to Nurse Ann's other two clients (choice A) may not address the underlying issue of a declining client and could lead to a delay in care. Asking other nurses for help (choice C) might not be the most efficient solution, as the supervisor is responsible for reassigning tasks. Nurse Ann continuing to care for all her assigned clients (choice D) may compromise the quality of care provided to the declining client and may spread her too thin, impacting all clients negatively.
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While working the 11 p.m. to 7 a.m. shift at the long-term care unit, the nurse gathers the nursing staff to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait, suspecting alcohol intoxication. What is the most appropriate action for the nurse to take?
- A. Contact the nursing supervisor.
- B. Tell the staff member that she is not allowed to administer medications.
- C. Ask the staff member how much alcohol she has consumed.
- D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.
Correct Answer: A
Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.
The LPN needs to delegate a task to the nurse aide who is new to the unit. Which of these is the best option for the nurse to choose in proceeding?
- A. Delegate the task to the nurse aide, confirm understanding, and follow up to ensure the task was safely and correctly done.
- B. Delegate the task to the nurse aide, watch them perform the task without them seeing you, and follow up to ensure the task was done safely and accurately.
- C. Delegate the task to the nurse aide, supervise if needed, and check in after the task to see if help is needed.
- D. Delegate the task to the nurse aide, ensure understanding of the task, and supervise the task being performed.
Correct Answer: B
Rationale: Delegation is transferring responsibility for a task but sharing its accountability. It is the delegator's responsibility to ensure that the delegatee understands the task before it is performed and to follow up afterward to ensure it was completed correctly and safely. Option B is the best choice because it allows the nurse to observe the nurse aide performing the task without pressure, which can provide insights into the aide's abilities and understanding. This method also allows for immediate feedback and correction if needed.
Choice A is incorrect because confirming understanding alone may not provide a complete picture of the aide's competence in performing the task. Choice C is incorrect as it suggests supervising only if needed, which may not provide adequate oversight for a new nurse aide. Choice D is incorrect because supervising the task being performed does not allow for an objective assessment of the aide's abilities and understanding.
Which of the following is not one of the four categories related to client care plans?
- A. privacy
- B. evaluation
- C. diagnosis
- D. outcome
Correct Answer: A
Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.
Upon admission, the client expresses a desire for an extra oxygen tank in their room due to a previous breathing issue. What is the most appropriate response?
- A. "I will make sure there is always an extra oxygen tank in your room."?
- B. "I will ask the previous nurse if the extra tank was needed."?
- C. "I will need to check if your insurance benefits would cover an additional oxygen tank."?
- D. "The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby."?
Correct Answer: D
Rationale: The appropriate response in this situation is to prioritize the availability of oxygen tanks for all patients in need. While it is understandable that the client may desire an extra tank for reassurance, the healthcare facility must ensure equitable distribution based on clinical need. Option A is incorrect because promising an always available extra tank may not be feasible and can set unrealistic expectations. Option B is not the best response as it focuses on past actions rather than addressing the current situation. Option C is not the most appropriate response at this time as the client's immediate need for an extra oxygen tank is the primary concern. Therefore, the best response is to emphasize the importance of equitable distribution of resources while acknowledging the client's request for an extra tank.
An LPN is having a conflict with another nurse during her shift. She has tried to discuss the issues with the nurse with no resolution. What is the most appropriate way for the LPN to proceed?
- A. Report the conflict to the director of nursing over the unit.
- B. Report the conflict to the assigned charge nurse of the unit.
- C. Report the conflict to the nurse manager of the unit.
- D. Discuss the conflict with the other nurse to attempt resolution of the issue.
Correct Answer: B
Rationale: In this scenario, the most appropriate way for the LPN to proceed is to report the conflict to the assigned charge nurse of the unit. Following the chain of command is crucial in a professional setting to address conflicts effectively. Reporting the issue to the charge nurse, who is the immediate supervisor, allows for a structured approach to resolving the conflict. Reporting directly to higher levels such as the director of nursing or nurse manager may bypass the appropriate hierarchy and could create unnecessary tension. Attempting to resolve the issue independently with the other nurse may not be effective if previous attempts have failed, making it essential to involve the immediate supervisor.