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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.
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The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?
- A. Administered two medications to the same client at the wrong time.
- B. Documented data in the clinical record before assessing client's condition.
- C. Served a diet tray to a client who was NPO for a scheduled procedure.
- D. Changed work assignments without prior approval from charge nurse.
Correct Answer: B
Rationale: Falsifying documentation by recording data before assessment is a serious ethical breach, warranting PRC review. Medication errors, serving a tray, or changing assignments are less severe and can be addressed through counseling.
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.
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.
After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range: International Normalized Ratio [0.8 to 1.1], Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)], Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)], Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]
- A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).
- B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.
- C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).
- D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).
Correct Answer: A
Rationale: A BNP of 1000 pg/mL indicates severe heart failure, requiring urgent interventions like oxygen and diuretics. The INR is therapeutic, glucose is mildly elevated, and potassium is normal, making these less urgent.
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.