Nokea
The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?
- A. A client with chest tubes secondary to a stab wound to the chest.
- B. A client in end-stage liver failure who is experiencing esophageal bleeding.
- C. A client with multisystem failure secondary to a motor vehicle collision.
- D. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
Correct Answer: A
Rationale: The client with chest tubes has a stable condition suitable for the new graduate's skills.
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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.
An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor, demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?
- A. Discuss with the family about placing the client in a skilled care facility.
- B. Determine if the client is manifesting other neurologic changes.
- C. Apply a restraining device to prevent the client from self injury.
- D. Request family members report when the client is left alone.
Correct Answer: B
Rationale: Assessing for neurologic changes identifies potential causes of agitation, such as delirium or hypoxia.
A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
- A. Let each family member ask a question one at a time.
- B. Request the healthcare provider to speak with the family.
- C. Page a chaplain on call to be present for questions.
- D. Ask the family to identify a specific spokesperson.
Correct Answer: D
Rationale: Identifying a spokesperson streamlines communication, reducing confusion and repetitive questions.
A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?
- A. Offer to switch the nurse's shift assignments to afternoons or evenings.
- B. Stress the expectation that the nurse will arrive on time for all scheduled shifts.
- C. Caution the nurse that one more tardiness will result in probational employment.
- D. Have the nurse sign a copy of the hospital employee attendance policy.
Correct Answer: B
Rationale: Stressing the expectation of punctuality clearly communicates standards and promotes accountability.
During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe an as needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. Which instruction should the nurse provide the unit clerk?
- A. Tell the healthcare provider the nurse will return the phone call as soon as possible.
- B. Remain with this client and monitor the vital signs while the nurse takes the call.
- C. Ask the healthcare provider to remain on 'hold' until the nurse can confirm the prescription.
- D. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.
Correct Answer: A
Rationale: The nurse must receive prescriptions directly, prioritizing the unstable client's care.