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The nurse is reviewing leadership and management concepts with a student nurse. Which of the following statements by the student nurse would require follow-up?
- A. The Laissez-faire leadership style is a passive leadership approach.
- B. A registered nurse (RN) may delegate accountability to a licensed practical/vocational nurse (LPN/VN).
- C. The rights of delegation include task, circumstance, person, direction, supervision.
- D. The nurse practice act defines roles and responsibilities of nursing professionals.
Correct Answer: B
Rationale: The statement that RNs can delegate accountability to LPNs (B) is incorrect, as RNs remain accountable for delegated tasks. Laissez-faire leadership (A), delegation rights (C), and nurse practice acts (D) are accurately described, requiring no follow-up.
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The charge nurse is making assignments in the intensive care unit (ICU) and is making client assignments for a nurse floated from the medical-surgical (med-surg) unit. Which client would be appropriate to assign to the nurse floated from med-surg?
- A. A client with bacteremia who is suspected of developing shock.
- B. A client requiring the titration of intravenous (IV) vasopressors based on hemodynamic monitoring.
- C. A client receiving intravenous (IV) antibiotics and nebulizer treatments for pneumonia.
- D. A client with targeted temperature management three hours after experiencing cardiac arrest.
Correct Answer: C
Rationale: A client receiving IV antibiotics and nebulizers for pneumonia (C) is stable and aligns with med-surg skills, suitable for a float nurse. Bacteremia with shock (A), vasopressor titration (B), and targeted hypothermia (D) require ICU expertise.
The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who
- A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
- B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
- C. has a substance use disorder and refuses to attend group therapy for the second time.
- D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
Correct Answer: A
Rationale: Pacing and mumbling in psychosis (A) suggest agitation or worsening symptoms, posing a safety risk requiring immediate follow-up. Increased hand washing (B), therapy refusal (C), and abuse allegations (D) are less urgent, as they are chronic or procedural.
The nurse is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed
- A. olanzapine reporting muscle stiffness and feeling hot.
- B. haloperidol reporting blurred vision and constipation.
- C. clozapine reporting occasional twitches of the mouth.
- D. aripiprazole reporting feeling very restless.
Correct Answer: A
Rationale: Muscle stiffness and feeling hot with olanzapine (A) suggest neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Blurred vision/constipation (B), mouth twitches (C), and restlessness (D) are less urgent side effects.
The nurse is providing the client with information regarding advanced directives. The nurse understands that giving this information supports the client's
- A. right to privacy.
- B. right to emergency care regardless of the ability to pay.
- C. C. self-determination.
- D. D. ability to receive appropriate treatment for their pain.
Correct Answer: C
Rationale: Advance directive discussions support self-determination (C) by empowering clients to make healthcare decisions. Privacy (A), emergency care (B), and pain treatment (D) are not directly related to advance directives.
The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply.
- A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow.
- B. Obtains orthostatic blood pressure by having the client stand first.
- C. Places the cane on the unaffected side of a client who had a stroke.
- D. Provides a hot foot soak for a client with diabetes mellitus.
- E. Obtains a urine culture from an indwelling urinary catheter.
Correct Answer: B, D, E
Rationale: Standing first for orthostatic BP (B) risks syncope, hot foot soaks for diabetes (D) risk burns due to neuropathy, and urine culture collection (E) requires sterile technique, all inappropriate for UAPs. Range of motion (A) and cane placement (C) are correct UAP tasks.