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The nurse is precepting a newly hired nurse on the medical-surgical unit. Which of the following actions, if performed first by the newly hired nurse, would demonstrate appropriate prioritization?
- A. Initiates a referral for a client needing home health care.
- B. Performs a central line dressing change on a client receiving 0.9% saline infusion.
- C. Collects a urine specimen from a client's indwelling urinary catheter.
- D. Obtains capillary blood glucose for a client receiving continuous regular insulin.
Correct Answer: D
Rationale: Obtaining blood glucose for a client on continuous insulin (D) is the priority to prevent hypo- or hyperglycemia, which can be life-threatening. Home health referral (A), dressing change (B), and urine collection (C) are important but less urgent, as they do not address immediate physiological risks.
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The nurse manager plans to establish quality metrics for the nursing unit based on national metrics and compare them to other healthcare organizations. This process is identified as
- A. benchmarking.
- B. continuous quality improvement.
- C. performance improvement.
- D. quality management.
Correct Answer: A
Rationale: Comparing unit metrics to national standards (A) is benchmarking, a process to measure performance against external standards. Continuous quality improvement (B), performance improvement (C), and quality management (D) are broader processes, but benchmarking is specific to this action.
The nurse is caring for a client with diabetic ketoacidosis and is prescribed a bolus of regular insulin followed by a continuous infusion of regular insulin. Prior to starting the continuous infusion, the nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Complete an incident report
- C. Assess the client for hypoglycemia
- D. Withhold the insulin infusion
Correct Answer: C
Rationale: Administering a 10-fold insulin overdose (C) risks severe hypoglycemia, so assessing the client immediately is critical to detect and treat low glucose. Notifying the PHCP (A), reporting (B), and withholding infusion (D) follow but are less urgent than client assessment.
The registered nurse (RN) is planning client care assignments. Which client would be appropriate to assign to the licensed practical/vocational nurse (LPN/VN)? A client
- A. with Guillain-Barre syndrome client reporting dyspnea while at rest.
- B. with stage 3 and 4 pressure injuries present in the sacral area.
- C. 2 hours postoperative total laryngectomy.
- D. awaiting a referral for outpatient diabetic support services.
Correct Answer: D
Rationale: A client awaiting a referral for diabetic support services (D) is stable and suitable for LPN care, involving coordination within scope. Guillain-Barré syndrome with dyspnea (A), severe pressure injuries (B), and recent laryngectomy (C) require RN assessment due to critical or complex needs.
The nurse is recommending a change in the healthcare facility's policy and procedure regarding usage of restraint. To ensure that the nurse is providing findings from the highest quality of evidence, the nurse should include information from a
- A. detailed expert opinion.
- B. systematic review.
- C. quantitative study.
- D. qualitative study.
Correct Answer: B
Rationale: Systematic reviews (B) provide the highest quality evidence by synthesizing multiple studies, ideal for policy changes like restraint use. Expert opinions (A), quantitative (C), and qualitative studies (D) are lower in the evidence hierarchy.
The charge nurse is in charge on a medical floor. The assignment includes a nursing assistant to transfer a client with a mechanical lift, within their scope. When the assistant says, 'I don’t know how to use the lift,' how should the nurse respond?
- A. It’s your job to know. You were trained; it’s in your description.'
- B. Your checklist shows you were competent in lifts during orientation.'
- C. Thanks for telling me. I’ll work with you to transfer safely.'
- D. No problem. I’ll reassign the transfer to another assistant.'
Correct Answer: C
Rationale: Offering to work with the assistant to transfer safely (C) ensures client safety and provides training, addressing the knowledge gap. Blaming (A), referencing past competency (B), or reassigning (D) do not promote learning or safety.