Nokea
Nurse receives four phone calls from pregnant women in their last trimester of pregnancy. Which call should be answered first?
- A. Client can't sleep supine because shortness of breath
- B. Client with frequent heartburn
- C. Client who can't remove wedding ring
- D. Client with frequent non-painful uterine contractions
Correct Answer: A
Rationale: The nurse must prioritize the client with shortness of breath when supine, a potential sign of late-pregnancy complications like preeclampsia or heart strain, over heartburn, ring tightness, or non-painful contractions. Dyspnea signals respiratory or cardiac distress say, from fluid overload needing urgent assessment to prevent maternal-fetal harm. Heartburn's common, ring issues suggest edema (less acute), and contractions could be Braxton Hicks, not immediate labor. In nursing leadership, triaging this call first ensures safety; a delay might miss hypoxia, risking oxygen delivery to the fetus. Picture a 38-week pregnant woman gasping this demands swift action, guiding care prioritization in high-stakes obstetric settings effectively.
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You have recently been appointed as a unit manager. After 3 months, you notice that staff are not seeking your advice as frequently as they did during your first weeks as manager. This observation may suggest that:
- A. Staff no longer perceive you as an expert
- B. Staff have increasing confidence in their own decision making
- C. There has been erosion in your relationships with staff
- D. Staff are experiencing dissatisfaction with your leadership
Correct Answer: B
Rationale: Staff seeking less advice after three months likely signals growing confidence in their own decisions, a natural shift as they adjust to your leadership and rely on their skills. It's not necessarily expertise loss, eroded ties, or dissatisfaction context matters, but reduced dependence often marks autonomy, a positive outcome in a stable unit. New managers see this as staff adapt, suggesting your initial support built their competence, aligning with effective leadership fostering independence over time.
The nurse is assessing a client with suspected hyperphosphatemia. Which finding supports this diagnosis?
- A. Tetany
- B. Soft tissue calcification
- C. Muscle weakness
- D. Increased urine output
Correct Answer: B
Rationale: In suspected hyperphosphatemia, soft tissue calcification supports it, not tetany, weakness, or high output. High phosphate binds calcium deposits form, unlike hypocalcemia's tetany. Leadership notes this imagine stiffness; it guides treatment, aligning with electrolyte care effectively.
The ___ perspective suggests that people are motivated to maintain consistent beliefs about themselves, even when these beliefs are negative.
- A. Self-verification
- B. Self-esteem
- C. Self-enhancement
- D. Self-monitoring
Correct Answer: A
Rationale: Self-verification seeks consistency, unlike esteem, enhancement, or monitoring. Nurse leaders like honest self-view embody this, contrasting with boosting. In healthcare, it's authenticity, aligning leadership with truth.
A nurse is caring for a client who is postoperative following abdominal surgery and has a nasogastric (NG) tube to low intermittent suction. Which of the following findings should the nurse report to the provider?
- A. Absence of bowel sounds
- B. NG tube output of 200 mL in 4 hours
- C. Abdominal distension
- D. Gastric residual of 50 mL
Correct Answer: A
Rationale: Post-abdominal surgery, an NG tube to low intermittent suction decompresses the stomach, aiding recovery. Absence of bowel sounds indicates ileus paralysis of intestinal motility a potential complication like obstruction or peritonitis, requiring provider notification for imaging or intervention. NG output of 200 mL in 4 hours (50 mL/hr) is expected, removing fluid or gas, while distension may occur but isn't urgent unless worsening with other signs. Gastric residual of 50 mL is minimal, not concerning with suction. Absent bowel sounds signal a critical deviation, demanding prompt reporting to prevent escalation, reflecting the nurse's role in vigilant postoperative monitoring.
A nurse manager is implementing a team nursing approach on his unit, hiring licensed practical nurses (LPNs) and assistive personnel (AP) as additional staff. Which of the following actions should the nurse manager take to facilitate acceptance of this change?
- A. Introduce the new approach and facilitate the development of a task force to plan implementation
- B. Announce the change and expect immediate compliance
- C. Train only the new staff on the approach
- D. Leave the staff to adapt on their own
Correct Answer: A
Rationale: Implementing a team nursing approach requires staff buy-in to ensure smooth adoption and effective collaboration. Introducing the new approach and creating a task force to plan its implementation actively involves the existing staff, giving them a sense of ownership and control over the change process. This strategy fosters acceptance by addressing concerns, encouraging input, and building a collaborative environment, which is critical in healthcare settings where teamwork directly impacts patient outcomes. Simply announcing the change without engagement risks resistance, as staff may feel blindsided or undervalued. Training only new staff excludes current employees, potentially creating resentment or confusion, while leaving staff to adapt independently neglects the need for structured guidance. Involving staff in planning leverages their expertise, reduces anxiety about the unknown, and aligns with leadership principles that prioritize communication and inclusion, ultimately enhancing the transition to a team-based model.