Nokea
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?
- A. Discuss why visitors should not lie in the bed with the client.
- B. Notify the charge nurse that the visitor is lying on the client's bed.
- C. Explain that the client has the right to have a visitor lie on the bed.
- D. Instruct the UAP to ask the visitor to get off the client's bed.
Correct Answer: D
Rationale: Instructing the UAP to address the visitor maintains hygiene and safety efficiently.
You may also like to solve these questions
After implementation of new policies related to client identification prior to medication administration, the frequency of medication errors remains unchanged. Which should be the nurse manager's next action?
- A. Provide revised procedural updates through additional nursing staff education programs.
- B. Examine medication administration data to determine use of new policy by nursing staff.
- C. Investigate identified procedural variances in medication administration with nursing staff.
- D. Determine changes in procedure needed to reduce the frequency of medication errors.
Correct Answer: B
Rationale: Examining data assesses policy compliance, identifying gaps to address persistent errors.
A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?
- A. Explain that the family has a right to know of potential health problems.
- B. Advise the client to weigh all possible outcomes prior to the decision.
- C. Suggest to the family the value of genetic screening.
- D. Notify the health department of the client's condition.
Correct Answer: B
Rationale: Advising the client to weigh outcomes supports their autonomy while encouraging informed decision-making.
The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?
- A. Call for an assistant.
- B. Respond to the code.
- C. Close the room door.
- D. Finish the procedure.
Correct Answer: A
Rationale: Calling for an assistant maintains the lumbar puncture's safety while allowing the nurse to address the code promptly.
The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?
- A. 30 mL of serous fluid obtained from compression bulb device in last 4 hours.
- B. 40 mL per hour of dark, cloudy urine from urinary catheter in last 4 hours.
- C. 20 mL of serosanguinous drainage from chest tube in last 8 hours.
- D. No observable drainage from 3-day-old Penrose drain in last 8 hours.
Correct Answer: D
Rationale: No drainage from a Penrose drain may indicate obstruction or infection, requiring immediate assessment.
Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
- A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.
- B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
- C. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
- D. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
Correct Answer: C
Rationale: A UAP checking for fecal impaction is outside their scope, requiring immediate reassignment to a nurse.