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The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement surgery. Which action is most appropriate for the nurse to plan to implement to protect the knee joint?
- A. Applying both ice and a compression dressing to the knee while sitting.
- B. Obtaining a walker to minimize weight-bearing by the client on the affected leg.
- C. First applying a knee immobilizer and then elevating the affect leg while sitting.
- D. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place.
Correct Answer: C
Rationale: After a total knee replacement, as prescribed, the nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The leg is elevated while the client is sitting in the chair to minimize edema. A compression dressing should already be in place on the wound. Ice is not used unless prescribed. The surgeon prescribes the weight-bearing limits on the affected leg. A CPM machine is used only while the client is in bed and is initiated when prescribed.
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Which client should the nurse safely assign to the unlicensed assistive personnel (UAP)?
- A. A client requiring dressing changes
- B. A client requiring frequent ambulation
- C. A client on a bowel management program requiring rectal suppositories
- D. A client newly admitted with nausea, vomiting, and moderate neck pain
Correct Answer: B
Rationale: Assignment of tasks to UAP needs to be made based on job description, level of clinical competence, and state law. The client described in option 2 has needs, frequent ambulation, that can be met by UAP. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse.
The nurse is preparing the client's morning prescribed NPH insulin dose and notices a clumpy precipitate inside the insulin vial. Which action should the nurse implement?
- A. Draw the dose from a new vial.
- B. Draw up and administer the dose.
- C. Shake the vial in an attempt to disperse the clumps.
- D. Warm the bottle under running water to dissolve the clump.
Correct Answer: A
Rationale: The nurse should always inspect the vial of insulin before use for solution changes that may signify loss of potency. NPH insulin is normally uniformly cloudy. Clumping, frosting, and precipitates are signs of insulin damage. In this situation, because potency is questionable, it is safer to discard the vial and draw up the dose from a new vial.
A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family?
- A. Inform the friend to directly contact the family and offer assistance to them.
- B. Request that the friend come to the client's home during the next home health visit.
- C. Report the friend's call to the nurse manager for referral to the client's social worker.
- D. Assure the friend that there is no need for assistance since the nurse is visiting daily.
Correct Answer: A
Rationale: The nurse must uphold the client's rights and does not give any information regarding a client's care needs to anyone who is not directly involved in the client's care. To request that the friend come for teaching is a direct violation of the client's right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer the call to the nurse manager and social worker again assumes that the friend's assistance and involvement are desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option 1 directly refers the friend to the family.
A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the post-anesthesia care unit (PACU)?
- A. An apnea monitor
- B. A suction unit and oxygen
- C. A blood transfusion warmer
- D. An ampule of phytonadione
Correct Answer: B
Rationale: After thyroidectomy, respiratory distress can occur from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and suction equipment readily available and in working order if such an emergency were to arise. Apnea is not a problem associated with thyroidectomy, unless the client experienced respiratory arrest. Blood transfusions can be administered without a warmer, if necessary. Phytonadione would not be administered for a client who is hemorrhaging, unless deficiencies in clotting factors warrant its administration.
Which scenarios demonstrate a participative style of leadership? Select all that apply.
- A. The nurse manager presents a problem to the staff and tells the staff to solve the problem.
- B. The nurse manager arranges unit meetings for all shifts to deal with an identified problem.
- C. The nurse manager assesses a problem and informs the staff of the solution to be implemented.
- D. The nurse manager proposes several methods of dealing with a problem and invites team input.
- E. The nurse manager proposes several solutions to a problem and has the unit staff vote on the best option.
- F. The nurse manager considers staff input related to a problem but makes the final decision on implementation of the solution.
Correct Answer: B,D,F
Rationale: Participative leadership demonstrates an 'in-between' style, neither authoritarian nor democratic. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. The autocratic style of leadership is task oriented and directive. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. The democratic style of leadership involves a majority rule.