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Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.
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Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber’s signature on prescription within 24 hours
- D. Decline verbal prescription b/c it is not emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.
Incorrect Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.
Nurse is preparing in-service program about delegation. Which of following elements should she identify when presenting 5 rights of delegation? (Select all that apply.)
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. Right supervision/evaluation ensures appropriate oversight, right direction/communication is crucial for clear instructions, and right circumstances involve assessing if it is appropriate to delegate the task. Right client is not directly related to delegation, and right time is not one of the traditional 5 rights of delegation.
Nurse reviewing car seat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include?
- A. Use car seat that has 3-point harness
- B. Position car seat so that infant is rear-facing
- C. Secure car seat in front passenger seat of car
- D. Put soft padding in car seat behind infant's back & neck
Correct Answer: B
Rationale: The correct answer is B: Position car seat so that infant is rear-facing. This is crucial for newborn safety as it reduces the risk of injury in the event of a crash. Rear-facing car seats provide optimal support for the infant's head, neck, and spine. Choice A is incorrect because a 5-point harness is recommended for infants for better protection. Choice C is incorrect as the back seat is the safest location for a car seat. Choice D is incorrect because soft padding can compress in a crash, leading to injury.
Nurse is reviewing hand hygiene techniques with a group of APs. Which instructions should the nurse include when discussing handwashing? (Select all that apply.)
- A. Apply 3-5 mL of liquid soap to dry hands
- B. Wash hands with soap & water for at least 15 seconds
- C. Rinse hands with hot water
- D. Use a clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: Correct Answer: B, D
Rationale:
B: Washing hands with soap & water for at least 15 seconds is crucial to ensure thorough cleaning and removal of germs.
D: Using a clean paper towel to turn off hand faucets helps prevent recontamination of clean hands.
Incorrect Choices:
A: Applying 3-5 mL of liquid soap to dry hands is not specified in handwashing guidelines.
C: Rinsing hands with hot water can strip the skin of natural oils and may not be necessary for effective hand hygiene.
E: Allowing hands to air dry after washing may not be sufficient to eliminate germs and is not a recommended step in hand hygiene protocols.
Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct answers are B (Varicella), C (Polio), and E (Seasonal influenza). Varicella and seasonal influenza vaccines are recommended for preschoolers by the CDC to prevent the spread of these contagious diseases. Polio vaccine is important for preventing polio, a potentially serious disease that can be prevented through vaccination. Haemophilus influenzae type b, Hepatitis A, and the other choices are not typically part of the CDC's routine immunization recommendations for preschoolers. It is crucial for the nurse to include discussions on Varicella, Polio, and Seasonal influenza vaccines to ensure the children are protected from these preventable diseases.