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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 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.
A nurse is caring for a client who is admitted to the emergency department with suspected rhabdomyolysis. Which of the following interventions should the nurse anticipate implementing initially for this client?
- A. Administering intravenous fluids
- B. Monitoring the client’s liver enzymes
- C. Administering corticosteroids
- D. Initiating prophylactic antibiotic therapy
Correct Answer: A
Rationale: Intravenous fluids (A) are the initial intervention for rhabdomyolysis to prevent kidney damage by flushing myoglobin and maintaining urine output. Monitoring liver enzymes (B), corticosteroids (C), and antibiotics (D) are not primary interventions for this condition.
The nurse is preparing to sign a client's surgical consent form after the physician has explained the procedure to the client and family. As the client signs the form, she comments 'I really didn’t understand most of what the doctor said, but I have to have this procedure, so I want to sign.' Which is the appropriate nursing action?
- A. Witness the document, as the client states she wants to sign it.
- B. Notify the physician or nursing supervisor.
- C. Call the OR to cancel the procedure and reschedule at a later date.
- D. Explain the information she did not understand.
Correct Answer: B
Rationale: Notifying the physician or nursing supervisor (B) ensures informed consent, a legal and ethical requirement, by addressing the client’s lack of understanding. Witnessing without clarification (A) violates consent principles, canceling the procedure (C) is premature, and explaining as a nurse (D) may exceed the nurse’s role, as the physician should clarify procedure details.
The nurse serves as a witness to a client giving informed consent to the primary healthcare provider (PHCP). The nurse understands that by a client giving consent this respects the client's
- A. beneficence.
- B. autonomy.
- C. nonmaleficence.
- D. confidentiality.
Correct Answer: B
Rationale: Informed consent respects client autonomy (B), allowing self-determination in medical decisions, per ethical principles. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and confidentiality (D) protects information, but autonomy is central to consent.
The nurse is triaging clients who were involved in a bus accident. Which client should be prioritized for transport to the local trauma center? A client who
- A. has pain and significant swelling in the right forearm with an intact distal pulse and sensation.
- B. has profuse bleeding from a chest laceration and is experiencing apnea.
- C. has a crushed leg reporting no sensation and has no distal pulse.
- D. is experiencing severe anxiety and has abrasions on both arms.
Correct Answer: B
Rationale: Profuse chest bleeding and apnea (B) indicate immediate life-threatening airway and circulation compromise, requiring trauma center transport. Forearm swelling (A), crushed leg (C), and anxiety (D) are serious but less acute, as they have intact vital signs or are stable.