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The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?
- A. 30 mL of serous fluid obtained from compression bulb device in last 4 hours.
- B. 40 mL per hour of dark, cloudy urine from urinary catheter in last 4 hours.
- C. 20 mL of serosanguinous drainage from chest tube in last 8 hours.
- D. No observable drainage from 3-day-old Penrose drain in last 8 hours.
Correct Answer: D
Rationale: No drainage from a Penrose drain may indicate obstruction or infection, requiring immediate assessment.
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The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat and sleeps most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?
- A. Maintain in high Fowler's position.
- B. Report any change in urine color.
- C. Keep mucous membranes moist.
- D. Record the client's daily weight.
Correct Answer: C
Rationale: Keeping mucous membranes moist prevents discomfort and complications, a priority in palliative care.
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.
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
- A. Complete an adverse occurrence report.
- B. Obtain blood for coagulation studies.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: D
Rationale: Notifying the provider is critical to address the high bleeding risk from the medication error.
The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?
- A. Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit.
- B. The subclavian dressing change on a client diagnosed with inflammatory bowel disease.
- C. The admission assessment of a client diagnosed with bacterial pneumonia.
- D. The insertion of a Foley catheter for a client diagnosed with septicemia.
Correct Answer: D
Rationale: Foley catheter insertion is within the PN's scope, a task-based procedure suitable for their training.
The charge nurse is making assignments for a 15-bed skilled nursing unit with the staff of one nurse, two practical nurses (PN), and two unlicensed assistive personnel (UAP). Which client should be assigned to the PN?
- A. The client who had bilateral above-knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin intravenously.
- B. The client who is in end-stage Alzheimer's, who requires feeding, and is waiting for a long-term facility placement.
- C. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.
- D. The client who has right hemiplegia as the result of a cerebral vascular accident and receives continuous gastrostomy feedings per enteral pump.
Correct Answer: C
Rationale: The pneumonia client with oral medication is stable and within the PN's scope.