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The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?
- A. Call for an assistant.
- B. Respond to the code.
- C. Close the room door.
- D. Finish the procedure.
Correct Answer: A
Rationale: Calling for an assistant maintains the lumbar puncture's safety while allowing the nurse to address the code promptly.
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The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Administer a prescribed dose of a laxative.
- C. Teach the client about foods high in fiber.
- D. Assist the client to drink warm prune juice.
Correct Answer: D
Rationale: Assisting with warm prune juice is a safe, simple task within the aide's scope to relieve constipation.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
- A. Review the medication transcription with the nurse.
- B. Evaluate the client for symptoms of a drug interaction.
- C. Report the medication error to the nursing supervisor.
- D. Inform the pharmacist who dispensed the medication.
Correct Answer: C
Rationale: Reporting the error ensures proper documentation and follow-up for client safety.
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.
The charge nurse is assigning care to clients who are all receiving continuous intravenous medication infusions. The client receiving which medication infusion is best to assign to the licensed practical nurse (PN), rather than an RN?
- A. Nitroprusside sodium, an antihypertensive.
- B. Methotrexate, an antimetabolite chemotherapeutic agent.
- C. Octreotide acetate, an antidiarrheal agent.
- D. Amiodarone hydrochloride, an antiarrhythmic agent.
Correct Answer: C
Rationale: Octreotide infusion is stable and within the PN's scope, unlike high-risk medications requiring RN oversight.
A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?
- A. Offer to switch the nurse's shift assignments to afternoons or evenings.
- B. Stress the expectation that the nurse will arrive on time for all scheduled shifts.
- C. Caution the nurse that one more tardiness will result in probational employment.
- D. Have the nurse sign a copy of the hospital employee attendance policy.
Correct Answer: B
Rationale: Stressing the expectation of punctuality clearly communicates standards and promotes accountability.