Nokea
The charge nurse of a medical-surgical unit is informed that the nursing unit is short-staffed. Which task should the charge nurse delay in order to meet all client needs?
- A. Medication administration
- B. Daily baths
- C. Vital sign collection
- D. Hourly safety rounds
Correct Answer: B
Rationale: Daily baths (B) can be delayed as they are non-essential for immediate client safety. Medication administration (A), vital signs (C), and safety rounds (D) are critical for client care and cannot be postponed.
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The nurse knows that the concept of management is most closely associated with:
- A. Decision-making, problem-solving, and priority setting.
- B. Inspirational abilities and coaching.
- C. Visionary abilities and supervision.
- D. Motivational and visionary abilities.
Correct Answer: A
Rationale: Management is closely associated with decision-making, problem-solving, and priority setting (A), which are core functions of organizing and coordinating care. Inspirational (B), visionary (C), and motivational (D) abilities align more with leadership than management.
The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.
The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who
- A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C).
- B. has an indwelling urinary catheter and reports burning at the insertion site.
- C. has scant blood in their newly established ostomy pouch.
- D. has friends writing words on their fiberglass cast with different colored markers.
Correct Answer: A
Rationale: A fever of 101°F in Hirschsprung’s disease (A) suggests possible enterocolitis, a life-threatening complication requiring immediate follow-up. Catheter burning (B), scant ostomy blood (C), and cast writing (D) are less urgent, as they are expected or non-threatening.
The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN?
- A. The patient states she feels the need to urinate.
- B. Patient reports a pinching sensation as the catheter is advanced.
- C. The student nurse notes resistance when inflating the balloon.
- D. The student separates the labia majora and labia minora with non-dominant hand.
Correct Answer: C
Rationale: Resistance when inflating the catheter balloon (C) suggests improper placement (e.g., in urethra), risking trauma, requiring immediate RN intervention. Urge to urinate (A) and pinching (B) are normal, and labia separation (D) is correct technique.
The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who is
- A. receiving albuterol via a nebulizer and reports feeling 'nervous'.
- B. awaiting a home healthcare referral following total hip arthroplasty.
- C. six hours post-op from a hysterectomy and is reporting nausea.
- D. reporting that their arm is 'sleeping' after having a cast for a fracture applied three hours ago.
Correct Answer: D
Rationale: Numbness ('sleeping' arm) post-cast application (D) suggests possible compartment syndrome or nerve compression, a surgical emergency requiring immediate follow-up. Nervousness from albuterol (A) is expected, home health referral (B) is non-urgent, and post-op nausea (C) is common but less critical.