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The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?
- A. Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit.
- B. The subclavian dressing change on a client diagnosed with inflammatory bowel disease.
- C. The admission assessment of a client diagnosed with bacterial pneumonia.
- D. The insertion of a Foley catheter for a client diagnosed with septicemia.
Correct Answer: D
Rationale: Foley catheter insertion is within the PN's scope, a task-based procedure suitable for their training.
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Which client requires the most immediate intervention by the nurse?
- A. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- B. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6 F (38.1 C).
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: A
Rationale: Somnolence in acute kidney injury suggests uremic encephalopathy, requiring immediate neurological assessment.
A male college student is brought to an emergency clinic by his friends because they report that he has been vomiting for the past two days as a result of food poisoning. Laboratory findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor client's electrocardiogram continuously.
- B. Inject prescribed potassium chloride IV push slowly.
- C. Assess level of consciousness every 4 hours.
- D. Instruct client on dietary intake of potassium-rich foods.
Correct Answer: A
Rationale: Continuous ECG monitoring is critical due to hypokalemia's risk of causing life-threatening arrhythmias.
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.
An unlicensed assistive personnel (UAP) who is working on a skilled nursing unit is diagnosed with hepatitis A (HVA). Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. Which action should the nurse-manager take next?
- A. Observe the nurse for jaundice and icterus sclera.
- B. Review the immunization status of all unit employees.
- C. Refer the nurse to employee health for serological testing.
- D. Post an employee notice of the outbreak of HVA on the unit.
Correct Answer: C
Rationale: Serological testing confirms HVA, enabling prompt diagnosis and treatment.
After implementation of new policies related to client identification prior to medication administration, the frequency of medication errors remains unchanged. Which should be the nurse manager's next action?
- A. Provide revised procedural updates through additional nursing staff education programs.
- B. Examine medication administration data to determine use of new policy by nursing staff.
- C. Investigate identified procedural variances in medication administration with nursing staff.
- D. Determine changes in procedure needed to reduce the frequency of medication errors.
Correct Answer: B
Rationale: Examining data assesses policy compliance, identifying gaps to address persistent errors.