Nokea
The nurse is caring for a client who is post-op day 1 for a coronary artery bypass graft (CABG). The nurse knows that continuity of care for this client is ensured by doing which of the following? Select all that apply.
- A. using standardized handoff reports
- B. knowing how to perform a chart check
- C. following up on outstanding lab reports and incomplete orders
- D. knowing the proper procedures to transfer clients to another floor
Correct Answer: A,B,C,D
Rationale: Standardized handoffs, chart checks, following up on labs/orders, and proper transfer procedures all ensure continuity of care.
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An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?
- A. the client complaining of chest pain and nausea who is diaphoretic
- B. the client with a simple fracture of the radius from a fall on a staircase
- C. the client complaining of slight redness and itching at the IV site in his hand
- D. the client presenting with a sprained ankle from a tree branch falling on him
Correct Answer: A
Rationale: Chest pain, nausea, and diaphoresis suggest a potential myocardial infarction, a life-threatening condition requiring immediate attention. Options B, C, and D describe less urgent conditions.
The nurse is responsible for his own actions while on duty caring for clients. What is the name of this ethical principle? Fill in the blank.
- A. Accountability
Correct Answer: A
Rationale: Accountability is the ethical principle where nurses are responsible for their own actions and decisions in client care.
A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action?
- A. Work closely with the UAP during the shift and observe for any signs of impairment.
- B. Complete the bed bath without comment. The unit is already short one staff member.
- C. Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired.
- D. Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager.
Correct Answer: D
Rationale: The smell of alcohol suggests potential impairment, which poses a safety risk to clients. Reporting to the charge nurse ensures client safety and follows protocol. Options A, B, and C fail to address the potential risk adequately.
The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? Select all that apply.
- A. A sterile object is held below the table surface and returned to the sterile field.
- B. The outer inch of the sterile towel hangs over the side of the table.
- C. A partially emptied container of sterile betadine is replaced within the sterile field.
- D. Sterile packages are opened with the first edge away from the technician.
Correct Answer: A,B,C
Rationale: Holding a sterile object below the table surface, allowing the towel to hang over the edge, and replacing a partially used container all compromise sterility. Opening packages with the first edge away from the technician is correct technique.
A charge nurse is preparing client care assignments for the upcoming shift. A client who underwent a laminectomy is scheduled to return from the recovery care unit. Which staff member should receive this client?
- A. graduate nurse with 3 months of experience
- B. RN with 1 year of experience
- C. certified nursing assistant with 5 years of experience
- D. charge nurse with 2 years of experience
Correct Answer: B
Rationale: An RN with 1 year of experience has sufficient skills for post-laminectomy care. A CNA lacks the scope, and a graduate nurse may need more experience.