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The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?
- A. The acuity level of the clients on the unit.
- B. The physicians' plans to perform procedures on the unit.
- C. The number of clients leaving the unit for diagnostic tests.
- D. The skill level of the personnel staffing the unit.
Correct Answer: A
Rationale: Client acuity determines the intensity of care needed, directly impacting staffing requirements. Procedures, diagnostic tests, and staff skills are secondary considerations.
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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. Ask the family to identify a specific spokesperson.
- D. Page a chaplain on call to be present for questions.
Correct Answer: C
Rationale: Designating a spokesperson streamlines communication, reducing repetitive questions and respecting client privacy. Individual questioning, provider involvement, or chaplain support are less immediate solutions.
The nurse determines that an IV vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Record the patient's pulse volume distal to the IV site every hour.
- B. Reapply cold compresses to the site of the extravasation every hour.
- C. Dispose of the IV tubing after the infusion is discontinued.
- D. Teach the patient about the need to keep the extremity elevated.
Correct Answer: C
Rationale: Disposing of IV tubing is a routine task within the UAP's scope. Recording pulse volume, reapplying compresses, and teaching require clinical judgment, which are RN responsibilities.
The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?
- A. Call the hospital operator to determine if this is indeed a real emergency or a fire drill.
- B. Instruct the clients' family members to stay in the visitor waiting area until further notice.
- C. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner.
- D. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.
Correct Answer: D
Rationale: Keeping clients and visitors in rooms with closed doors follows the RACE protocol, containing fire and smoke. Calling the operator, directing to the waiting area, or evacuating may delay safety measures.
A 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 multisystem failure secondary to a motor vehicle collision.
- B. A client in end-stage liver failure who is experiencing esophageal bleeding.
- C. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
- D. A client with chest tubes secondary to a stab wound to the chest.
Correct Answer: D
Rationale: The client with chest tubes has stable needs manageable by a new graduate with recent training. Multisystem failure, liver failure, and ARDS require advanced skills better suited to experienced nurses.
The nurse determines that an elderly client with pneumonia has a nursing problem of 'altered nutrition, less than body requirements.' Which instruction should the nurse give the unlicensed assistive personnel (UAP) helping with the care of this client?
- A. Offer to assist the client with meal preparation and feeding.
- B. Thicken the client's liquids if aspiration seems likely.
- C. Listen to the client's breath sounds before and after meals.
- D. Assist the client in selecting high protein foods on the menu.
Correct Answer: A
Rationale: Assisting with feeding is within the UAP's scope and addresses the client's nutritional needs. Thickening liquids, listening to breath sounds, and selecting foods require RN judgment.