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The nurse is providing care for a patient recently transferred from the post-anesthesia care unit [PACU]. The chart indicates that the patient was medicated for pain 1 hour ago, yet the patient reports that he is experiencing extreme pain. He is not due for further medication until another 2 hours. How might the nurse intervene as a patient advocate?
- A. Contact the physician regarding the need for more effective pain management.
- B. Assist the patient to use non-pharmacological pain management strategies.
- C. Explain to the patient that giving the pain medication too soon can be dangerous.
- D. Provide a quiet environment to help the patient rest and cope with his pain level.
Correct Answer: A
Rationale: Contacting the physician (A) advocates for the patient by addressing uncontrolled pain, potentially adjusting the regimen. Non-pharmacological strategies (B), explaining risks (C), or providing a quiet environment (D) are supportive but do not directly address the need for better pain control.
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The Unlicensed Assistive Personnel (UAP) is helping a female patient with early ambulation postsurgery. The CNA has just applied a gait belt to the patient's waist. Which of the following actions by the CNA will need interference and correction by the supervising nurse?
- A. Holding onto the belt's outer edge or center, preventing the patient from leaning or drooping to one side.
- B. Pulling from the front of the belt, keeping forward momentum.
- C. Bringing the client to a nearby chair when she feels dizzy.
- D. Keeping the patient's body weight close to her own.
Correct Answer: B
Rationale: Pulling from the front of the gait belt (B) risks causing the client to lose balance or fall, requiring correction. Holding the belt (A), seating a dizzy client (C), and maintaining close body alignment (D) are appropriate and safe actions.
The nurse in the emergency department (ED) is caring for a client diagnosed with acute pancreatitis. The nurse should prioritize obtaining a prescription for
- A. intravenous fluids.
- B. ondansetron.
- C. the insertion of a nasogastric tube (NGT).
- D. fentanyl via patient-controlled analgesia.
Correct Answer: A
Rationale: IV fluids (A) are the priority in acute pancreatitis to correct hypovolemia and prevent organ failure, per clinical guidelines. Ondansetron (B), NGT (C), and fentanyl (D) address symptoms but are secondary to fluid resuscitation.
The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style?
- A. Authoritative
- B. Democratic
- C. C. Laissez-Faire
- D. D. Transactional
Correct Answer: B
Rationale: A unit-based council reflects a democratic leadership style (B), involving staff in decision-making. Authoritative (A) is directive, laissez-faire (C) is passive, and transactional (D) focuses on rewards and tasks, not shared governance.
When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward?
- A. Report the conflict to the director of nursing over the unit.
- B. Report the conflict to the nurse manager of the unit.
- C. Report the conflict to the assigned charge nurse of the unit.
- D. Discuss the conflict with another nurse to attempt resolution of the issue.
Correct Answer: B
Rationale: Reporting to the nurse manager (B) follows the chain of command for unresolved conflict, ensuring appropriate resolution. The director (A) is too high, the charge nurse (C) may lack authority, and discussing with another nurse (D) risks gossip and unprofessionalism.
The nurse has received the following information about assigned clients. The nurse should initially assess the client who is at
- A. 15 weeks gestation who reports not feeling any fetal movement.
- B. 28 weeks gestation who reports swollen feet and ankles.
- C. 36 weeks gestation who reports contractions that are irregular.
- D. 37 weeks gestation experiencing variable decelerations.
Correct Answer: D
Rationale: Variable decelerations at 37 weeks (D) indicate possible umbilical cord compression, a fetal emergency requiring immediate assessment. No fetal movement at 15 weeks (A) is normal, edema at 28 weeks (B) is common, and irregular contractions at 36 weeks (C) are non-urgent.