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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.
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Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
- A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.
- B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
- C. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
- D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
Correct Answer: D
Rationale: Checking for fecal impaction is beyond the UAP's scope, risking client injury. The other assignments (transport, BP monitoring, blood retrieval) are within the respective staff's competencies.
A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?
- A. Notify the health department of the client's condition.
- B. Advise the client to weigh all possible outcomes prior to the decision.
- C. Suggest to the family the value of genetic screening.
- D. Explain that the family has a right to know of potential health problems.
Correct Answer: B
Rationale: Advising the client to consider outcomes respects her autonomy while encouraging informed decision-making. Notifying the health department, suggesting screening, or asserting family rights violate confidentiality or autonomy.
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.
An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100°F (37.8°C), blood pressure 98/50 mm Hg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Replace fluids intravenously based on intake and output.
- B. Record the amount of daily wound drainage.
- C. Assess skin condition and turgor for breakdown.
- D. Turn every 2 hours around the clock from side-to-side.
Correct Answer: A
Rationale: IV fluid replacement addresses hypovolemia and prevents shock, critical given the client's vital signs. Recording drainage, assessing skin, and turning are important but secondary to stabilizing fluid status.
A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?
- A. Review the need for the UAP to wear a face mask while in close contact with the client.
- B. Remind the UAP to apply a fitted respirator mask before entering the client's room.
- C. Assign the UAP to provide care for another client and assume full care of the client.
- D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
Correct Answer: A
Rationale: Reviewing the need for a face mask ensures proper droplet precautions for influenza, completing the UAP's PPE. A respirator is unnecessary, reassigning the UAP is impractical, and monitoring respiratory changes is secondary to infection control.