Nokea
The nurse is caring for assigned clients. The nurse should initially follow up on the client who is
- A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C).
- B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side.
- C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous.
- D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.
Correct Answer: B
Rationale: Absent breath sounds with a chest tube for pneumothorax (B) indicate a life-threatening complication, such as tube dislodgement or re-collapse, requiring immediate assessment. A fever post-hypophysectomy (A) suggests infection but is less urgent. Nervousness from albuterol (C) is a common side effect, and cramping during dialysis (D) is less critical unless severe.
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The nurse is discussing management styles with a colleague. Which of the following nursing leadership and management-related statements is accurate?
- A. Nurse managers possess personal accountability for not only their specific acts but also acts of delegation and supervision.
- B. Nurses and nurse managers are accountable for supervising others, except for unlicensed assistive personnel (UAP).
- C. When delegated to the appropriate person, the delegating nurse is no longer responsible for ensuring the task is performed correctly.
- D. Managing care entails micromanagement of the unit's staff.
Correct Answer: A
Rationale: Nurse managers are accountable for their actions and delegated tasks, including supervision (A), per nursing standards. UAPs are included in supervision (B), delegators remain responsible (C), and micromanagement (D) is ineffective, not a management goal.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. pancreatitis who has developed bruising around the umbilicus.
- B. a capillary blood glucose of 159 mg/dL (8.83 mmol/L) [70-110 mg/dL; 4-6 mmol/L] while receiving total parenteral nutrition.
- C. a blood pressure of 156/92 mmHg who sustained an ischemic stroke six hours ago.
- D. stable angina reporting headache while receiving nitroglycerin via transdermal patch.
Correct Answer: A
Rationale: Umbilical bruising in pancreatitis (A) suggests Cullen’s sign, indicating possible retroperitoneal hemorrhage, a life-threatening emergency. Mild hyperglycemia (B), elevated BP post-stroke (C), and nitroglycerin headache (D) are less urgent, as they are expected or manageable.
Which of the following clients should the nurse assess first when preparing to do initial rounds?
- A. The client with diabetes who is being discharged today.
- B. A 32-year-old female with a tracheostomy experiencing copious secretions.
- C. A 16-year-old scheduled for physical therapy this morning.
- D. An 80-year-old male with a decubitus ulcer that needs a dressing change.
Correct Answer: B
Rationale: Copious tracheostomy secretions (B) pose an immediate airway obstruction risk, requiring first assessment to ensure patency. Diabetes discharge (A), physical therapy (C), and ulcer dressing (D) are less urgent, as they do not threaten immediate airway compromise.
The registered nurse (RN) is working with two licensed/practical vocational nurses (LPN/VN) in the emergency department (ED). The RN assigns duties to one LPN/VN to administer prescribed medications for all clients and the other LPN/VN to perform medication reconciliation and obtain ordered 12-lead electrocardiograms (ECG). Which care delivery model is the RN utilizing?
- A. Team nursing
- B. Case management
- C. Functional nursing
- D. Primary nursing
Correct Answer: C
Rationale: Assigning specific tasks (medication administration, reconciliation, ECGs) to LPN/VNs (C) reflects functional nursing, where tasks are divided based on skill. Team nursing (A) involves collaborative care, case management (B) focuses on coordination, and primary nursing (D) assigns one nurse per client.
The nurse manager is completing an annual performance evaluation of a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply.
- A. The nurses’ bar-code medication administration scan rate
- B. The number of times the nurse has been absent or tardy
- C. The nurse achieving a national certification
- D. The nurses’ performance compared to other staff nurses
- E. The number of medication errors the nurse has self-reported.
Correct Answer: A, B, C, E
Rationale: Bar-code scan rate (A), absences/tardiness (B), national certification (C), and self-reported errors (E) are objective metrics for evaluation. Comparing to other nurses (D) is subjective and biased, inappropriate for inclusion.