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The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
- A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
- B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
- C. Renal transplant yesterday, complaining of flank pain and who states, 'it's hot in here.'
- D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
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A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?
- A. Can the equipment be updated each year?
- B. How many departments can use this equipment?
- C. Is the cost of equipment reasonable?
- D. Will the equipment require annual repair?
Correct Answer: B
Rationale: The number of departments using the equipment maximizes its benefit and cost-effectiveness across the organization. Updates, cost, and repairs are important but secondary to the equipment's overall utility.
The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse manager?
- A. Contact the healthcare provider to ensure that a prescription for restraints was written.
- B. Advise the staff nurse to remove the restraints from the client's wrists.
- C. Close the door to the room to avoid disturbing other clients in nearby rooms.
- D. Determine if the client has an as needed (PRN) prescription for an antianxiety agent
Correct Answer: B
Rationale: Removing restraints is the priority as they are unjustified for staff convenience and violate client rights. Checking for a prescription, closing the door, or considering antianxiety medication do not address the immediate ethical and safety concerns.
Following a six-week refresher course, a female nurse who has been out of the workforce for 10 years is assigned to a medical unit for orientation. After the first week of orientation, the charge nurse notes that the orientee is overwhelmed by her daily assignments, which are less than one-half the assignments of the regular staff, and the assignments are incomplete at the end of each day. The following week, which action is best for the charge nurse to take?
- A. Wait until the end of the second week to see if the orientee is able to complete her assignments.
- B. Assign the orientee to work with an experienced nurse who is a long-time, efficient employee.
- C. Inform the supervisor that for client safety this nurse should be assigned to a slower-paced unit.
- D. Talk to the orientee and ask her if she has considered working in a less stressful environment.
Correct Answer: B
Rationale: Pairing with an experienced nurse provides mentorship, enhancing skills and confidence. Waiting, transferring, or suggesting a less stressful environment may delay support or undermine the orientee's potential.
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
- B. Heparin in Normal Saline prescribed for deep vein thrombosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Regular insulin in Normal Saline prescribed for ketoacidosis.
Correct Answer: A
Rationale: Ceftriaxone can be safely administered by gravity infusion with nurse monitoring, as its dosing is less sensitive to minor flow rate variations. Heparin, magnesium, and insulin require precise infusion rates due to risks of bleeding, toxicity, or glucose imbalances, necessitating an IV pump.
The nurse manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse manager respond?
- A. Choose to send another nurse who is more receptive because the older nurse is not interested.
- B. Ask the nurse why she thinks there is no need for an in-service program about these emergencies.
- C. Inform the older nurse that in-service is not optional and her scheduled attendance is mandatory.
- D. Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.
Correct Answer: D
Rationale: Encouraging the nurse to share concerns fosters collaboration and addresses barriers to participation, enhancing engagement. Sending another nurse, questioning her views confrontationally, or mandating attendance may create resentment or fail to address her concerns effectively.