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The nurse manager has been made aware of the following staff nurse issues. The manager should initially follow up on the staff nurse who
- A. falsified documentation on a client discharged within the last 24 hours.
- B. needs assistance completing an incident report about a medication administration error on the previous shift.
- C. was thirty minutes late and tardy to their shift and is not wearing the correct gown uniform.
- D. is suspected of alcohol impairment and is precepting a newly hired nurse.
Correct Answer: D
Rationale: Suspected alcohol impairment while precepting (C) poses an immediate safety risk to clients and staff, requiring immediate immediate manager intervention. Falsified documentation (D), incident report assistance (A), and tardiness/uniform issues (B) are serious but less urgent than impairment.
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The nurse is caring for assigned clients. The nurse should initially assess the client who has
- A. left pulmonary empyema, a temperature of 102.4°F (39.1°C), and a pulse of 104.
- B. gentle bubbling in the water seal chamber of their chest tube when exhaling.
- C. a right pleural effusion and has decreased tactile fremitus in the right lobe.
- D. pneumonia and has a pulse oximetry of 90% while on 4 liters of nasal cannula oxygen.
Correct Answer: A
Rationale: Fever (102.4°F) and tachycardia (104) in empyema (A) suggest worsening infection or sepsis, requiring immediate assessment. Chest tube bubbling (B) is normal, pleural effusion findings (C) are expected, and 90% saturation (D) is stable with oxygen.
The nurse manager is conducting a staff in-service and announces that the staff nurses may decide when to take meal breaks, and the assignment for new admissions may be decided upon themselves. The nurse manager is demonstrating
- A. authoritative leadership style.
- B. democratic leadership style.
- C. participative leadership style.
- D. laissez-faire leadership style.
Correct Answer: D
Rationale: Allowing staff to decide meal breaks and assignments (D) reflects a laissez-faire leadership style, characterized by minimal direction and high autonomy. Authoritative (A) is directive, democratic/participative (B, C) involve shared decision-making but with more guidance.
The nurse is assisting the risk manager in reviewing a serious medication error. Which process should the nurse recommend be used to identify the origin of the issue and potential solution?
- A. Root cause analysis
- B. Collective bargaining
- C. Six Sigma
- D. Team STEPPS program
Correct Answer: A
Rationale: Root cause analysis (A) is the standard process to identify the origin of a medication error and develop solutions by analyzing contributing factors. Collective bargaining (B) is labor-related, Six Sigma (C) is a quality methodology, and Team STEPPS (D) focuses on teamwork, none specific to error investigation.
The nurse cares for an infant undergoing a surgical repair of a total anomalous pulmonary venous return tomorrow. The doctor has talked to the parents and obtained consent. The mother tells the nurse, 'I'm not so sure about this. What if my baby dies?' The nurse's most appropriate response is:
- A. Explain the procedure to the mother.
- B. Notify the surgical team and have them come back to speak with the mother again.
- C. Reassure the mother that everything will go as planned.
- D. Tell the mother that because she has already signed the consent, she cannot change her mind now.
Correct Answer: B
Rationale: Notifying the surgical team (B) ensures the mother’s concerns are addressed by the provider, respecting her need for clarification. Explaining the procedure (A) is the physician’s role, false reassurance (C) is inappropriate, and stating consent is irrevocable (D) is incorrect and dismissive.
The nurse has become aware of the following client situations. The nurse should first follow up with the client who
- A. has an irregular pulse and is receiving treatment for atrial fibrillation.
- B. has influenza and had an increase in temperature to 102°F (39°C).
- C. is receiving nebulizer treatments for asthma that suddenly stops wheezing.
- D. has an indwelling urinary catheter and reports burning at the insertion site.
Correct Answer: C
Rationale: Sudden cessation of wheezing in asthma (C) may indicate severe airway obstruction, a life-threatening emergency. Irregular pulse (A), fever with influenza (B), and catheter burning (D) are concerning but less immediately critical.