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The nurse has been tasked with developing and leading a multidisciplinary team to improve client safety and has been informed that previous group formations were unsuccessful due to poor team dynamics. When developing and leading this committee, it is essential that the nurse initially
- A. develop a code of conduct for the team.
- B. review how the team will be evaluated.
- C. review the goals for the team.
- D. establish deadlines for the team.
Correct Answer: C
Rationale: Reviewing team goals (C) initially aligns members toward a common purpose, addressing poor dynamics by fostering collaboration. A code of conduct (A), evaluation methods (B), and deadlines (D) are important but secondary to establishing shared objectives.
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[Orders ]
olanzapine 2.5 mg by mouth daily
obtain daily weights
12-lead electrocardiogram
consult nutritional services
The nurse is reviewing the physician orders for a client admitted with anorexia nervosa reporting weakness and abdominal distention. The nurse should prioritize:
- A. administering olanzapine.
- B. consulting nutritional services.
- C. performing the 12-lead electrocardiogram.
- D. weighing the client.
Correct Answer: C
Rationale: The client with anorexia nervosa reporting abdominal distention and weakness is concerning for hypokalemia. The nurse should prioritize performing the 12-lead electrocardiogram because cardiovascular collapse may occur if the client's physical symptoms go unrecognized and untreated. Additional testing is required, including a complete metabolic panel and magnesium level. Features of hypokalemia on the electrocardiogram include U-wave development, ST depression, and shallow, flat, or inverted T wave.
The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply.
- A. Gloves being worn to pass out meal trays
- B. Sterile water used to irrigate nasogastric tubes
- C. Dedicated blood pressure cuffs for clients with contact precautions
- D. Sterile gloves used to provide perineal care during bed baths
- E. New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN)
Correct Answer: A, D
Rationale: Wearing gloves for meal tray distribution (A) and sterile gloves for perineal care (D) are excessive, as non-sterile gloves suffice, wasting resources. Sterile water for NG irrigation (B), dedicated cuffs for precautions (C), and new IV tubing for TPN (E) are appropriate practices.
The nurse has attended a staff education program about sources of negligent lawsuits. It would indicate effective understanding if the nurse identifies which of the following is a source of a negligent lawsuit?
- A. The nurse documents care under another nurse's username and password
- B. The nurse takes pictures of a client's medical record and distributes them online
- C. The nurse does not notify the physician of a client's critical laboratory result
- D. The nurse treats their spouse in the acute care facility with prescribed medications
Correct Answer: A, B, C, D
Rationale: All options (A, B, C, D) are sources of negligent lawsuits: documenting under another’s credentials (A) is fraudulent, sharing medical records online (B) violates HIPAA, failing to report critical results (C) delays care, and treating a spouse with medications (D) breaches professional boundaries and scope of practice. Since the question implies multiple selections, all are correct.
The nurse is participating in a committee with the objective of promoting healthcare justice in the community. Which of the following recommendations should the nurse make to achieve the goal?
- A. establishing interdisciplinary collaboration between nursing and nutritional services
- B. providing more confidential waste containers at local drug stores
- C. offering free telehealth offerings in underserved areas of the community
- D. offering inpatient clients the ability to select their meal times
Correct Answer: C
Rationale: Free telehealth in underserved areas (C) promotes healthcare justice by improving access for disadvantaged populations. Interdisciplinary collaboration (A), waste containers (B), and meal time selection (D) are beneficial but less directly address equitable access.
The nurse is caring for assigned clients. The nurse should initially
- A. evaluate a client’s Mantoux test for tuberculosis tuberculin skin (TB) test for reactivity 48 hours after it has been administered.
- B. assess a client with atrial fibrillation who has an irregular pulse (P) of 90 beats/minute.
- C. apply the catheter prescribed medication to the lumbar back region of a client with chronic pain.
- D. administer the prescribed antibiotic scheduled for a client with peritonitis.
Correct Answer: D
Rationale: Administering antibiotics for peritonitis (C) is the priority to treat life-threatening intra-abdominal infection. TB test evaluation (D), AF pulse assessment (B), and lidocaine patch application (A) are less urgent, as they address stable or chronic conditions.