Nokea
The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?
- A. Administered two medications to the same client at the wrong time.
- B. Documented data in the clinical record before assessing client's condition.
- C. Served a diet tray to a client who was NPO for a scheduled procedure.
- D. Changed work assignments without prior approval from charge nurse.
Correct Answer: B
Rationale: Falsifying documentation by recording data before assessment is a serious ethical breach, warranting PRC review. Medication errors, serving a tray, or changing assignments are less severe and can be addressed through counseling.
You may also like to solve these questions
Which client requires the most immediate intervention by the nurse?
- A. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).
- B. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: B
Rationale: The client with acute kidney injury and unresponsiveness likely has uremic encephalopathy, a life-threatening condition requiring immediate intervention. The other clients' conditions are less urgent as they are receiving appropriate treatments.
The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
- A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
- B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
- C. Renal transplant yesterday, complaining of flank pain and who states, 'it's hot in here.'
- D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
The smell of cigarette smoke is coming from a client's bathroom. Which action should the nurse implement first?
- A. Document the occurrence in the client's record.
- B. Obtain a prescription for a nicotine patch during hospitalization.
- C. Educate the client about the hospital smoking policy.
- D. Notify the charge nurse about the situation immediately.
Correct Answer: D
Rationale: Notifying the charge nurse ensures immediate enforcement of the no-smoking policy to prevent fire risks. Documenting, prescribing patches, or educating are secondary actions.
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control. Play time, parent instruction, and room assignment are secondary.