Nokea
The charge nurse is orientating a newly hired nurse to the charge nurse role. Which observation by the charge nurse requires follow-up? The newly hired nurse Select all that apply.
- A. requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology.
- B. asks the licensed practical/vocational nurse (LPN/VN) to witness informed consent for a client scheduled for surgery.
- C. instructs the licensed practical/vocational nurse (LPN/VN) to review orders just written by the physician.
- D. assks the unlicensed assistive personnel (UAP) to transport blood specimens to the lab.
- E. assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN).
Correct Answer: A, B
Rationale: Transporting a client with respiratory distress (A) by a UAP is unsafe, as they require monitoring. An LPN witnessing consent (B) is outside their scope; RNs or providers typically do this. Reviewing orders (C), transporting specimens (D), and assigning a stable post-catheterization client (E) are appropriate.
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The nurse is caring for assigned clients. The nurse should initially assess the client who
- A. is recovering from a femoral angioplasty and reports their foot is falling asleep.
- B. has diabetes mellitus and refused their prescribed glargine insulin.
- C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14.
- D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.
Correct Answer: A
Rationale: Numbness post-femoral angioplasty (A) suggests vascular compromise, such as occlusion, requiring immediate assessment. Insulin refusal (B), stable GCS post-alteplase (C), and constipation in spinal injury (D) are less urgent.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- B. with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway.
- C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic.
- D. one day postoperative from an open cholecystectomy with green drainage from the t-tube.
Correct Answer: C
Rationale: Severe headache and diaphoresis in a T6 spinal injury (C) suggest autonomic dysreflexia, a life-threatening emergency. COPD shortness of breath (B), femur fracture pain (A), and t-tube drainage (D) are less urgent.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP?
- A. Obtain a tympanic temperature for a client who received naproxen one hour ago
- B. Record and empty a closed suction drain for a client recovering from a mastectomy
- C. Assist a client in picking out low-sodium foods on their lunch menu
- D. Transport a client receiving an infusion of dopamine to the intensive care unit
Correct Answer: A
Rationale: Obtaining a tympanic temperature (A) is a routine task within UAP scope. Recording drain output (B), dietary education (C), and transporting a client on dopamine (D) require nursing judgment or monitoring.
A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.
- A. Remind the patient of why breast feeding is the best method of infant feeding.
- B. Request a referral to the lactation consultant.
- C. Determine the patient's knowledge base related to infant feeding options.
- D. Accept the patient's decision without further discussion.
Correct Answer: C
Rationale: Determining the patient’s knowledge base (C) respects her autonomy while ensuring informed decision-making, aligning with patient advocacy. Reminding about breastfeeding (A) or referring to a consultant (B) may pressure the patient, and accepting without discussion (D) neglects education.
The nursing supervisor has implemented a new assignment system for nursing staff. In order to reduce resistance to this new system, the nurse manager should
- A. Provide incentives to foster the change
- B. Allow nursing staff to discuss potential concerns
- C. Provide statistical support for the change
- D. Detail the changes in a multimedia presentation
Correct Answer: B
Rationale: Allowing staff to discuss concerns (B) reduces resistance by fostering open communication and involvement, addressing potential barriers. Incentives (A), statistics (C), and presentations (D) are supportive but less effective without staff input.