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The charge nurse is in charge on a medical floor. The assignment includes a nursing assistant to transfer a client with a mechanical lift, within their scope. When the assistant says, 'I don’t know how to use the lift,' how should the nurse respond?
- A. It’s your job to know. You were trained; it’s in your description.'
- B. Your checklist shows you were competent in lifts during orientation.'
- C. Thanks for telling me. I’ll work with you to transfer safely.'
- D. No problem. I’ll reassign the transfer to another assistant.'
Correct Answer: C
Rationale: Offering to work with the assistant to transfer safely (C) ensures client safety and provides training, addressing the knowledge gap. Blaming (A), referencing past competency (B), or reassigning (D) do not promote learning or safety.
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The charge nurse is planning client care assignments for the medical-surgical unit. Which client should the charge nurse assign to the nurse floated from labor and delivery? A client
- A. receiving a continuous infusion of heparin for pulmonary embolism.
- B. eight hours post-operative following an open appendectomy.
- C. with a water-seal chest tube for a pneumothorax.
- D. admitted with an exacerbation of congestive heart failure (CHF).
Correct Answer: B
Rationale: A post-operative appendectomy client (B) is stable and aligns with labor and delivery nurses’ skills in post-surgical care. Heparin infusion (A), chest tube (C), and CHF exacerbation (D) require specialized medical-surgical expertise.
You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children?
- A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.
- B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof.
- C. The cognitive development of young children impacts their understanding of death.
- D. The cognitive development of young children before 12 has no impact on their understanding of death
Correct Answer: C
Rationale: Cognitive development (C) influences how children, like the 8-year-old, understand death. Younger children may view death as reversible or temporary, while adolescents, like the 14-year-old, grasp its finality. Tailoring explanations to their developmental stage is essential. Options A and B are incorrect as children do have perspectives, and avoiding discussion (A) is unhelpful. Option D contradicts developmental psychology.
The nurse is planning client care assignments. Which task should be delegated to the unlicensed assistive personnel (UAP)?
- A. The initial ambulation of a client following a laparoscopic hernia repair.
- B. Feed a client who has dysphagia.
- C. Applying sequential compression devices to a client’s lower extremities.
- D. Calling in prescriptions to the local pharmacy for a client ready for discharge.
Correct Answer: C
Rationale: Applying sequential compression devices (C) is a non-clinical task within the UAP’s scope. Initial ambulation (A), feeding with dysphagia (B), and calling prescriptions (D) require clinical judgment or RN/LPN skills due to risk or complexity.
The nurse is caring for a client with a platelet count of 18,000 mm3 [150,000-400,000 mm3]. What is the priority action the nurse should take?
- A. Review the client's most recent liver function tests.
- B. Educate the client to notify staff before getting out of bed.
- C. Obtain and monitor the client's temperature.
- D. Encourage the client to turn, cough, and deep breathe.
Correct Answer: B
Rationale: Severe thrombocytopenia (18,000 mm3) (B) risks bleeding, so educating the client to notify staff before moving prevents injury. Liver tests (A), temperature (C), and respiratory exercises (D) are secondary to immediate safety measures.
The Unlicensed Assistive Personnel (UAP) is helping a female patient with early ambulation postsurgery. The CNA has just applied a gait belt to the patient's waist. Which of the following actions by the CNA will need interference and correction by the supervising nurse?
- A. Holding onto the belt's outer edge or center, preventing the patient from leaning or drooping to one side.
- B. Pulling from the front of the belt, keeping forward momentum.
- C. Bringing the client to a nearby chair when she feels dizzy.
- D. Keeping the patient's body weight close to her own.
Correct Answer: B
Rationale: Pulling from the front of the gait belt (B) risks causing the client to lose balance or fall, requiring correction. Holding the belt (A), seating a dizzy client (C), and maintaining close body alignment (D) are appropriate and safe actions.