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The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best?
- A. Call the staff nurse in and place them on a work improvement plan after a 3-day suspension
- B. Have the other staff gather additional information on the tardy staff member
- C. Call the staff nurse in for an interview to investigate the problem and possible solutions
- D. Assign a mentor to assist the staff member in arriving on time
Correct Answer: C
Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems. Choice A is incorrect as it immediately involves suspension without investigation or support. Choice B is not the best course of action as it does not involve direct communication with the staff member in question. Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.
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A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?
- A. Instruct the child to extend the affected knee
- B. Perform range of motion exercises on both knees
- C. Compare the appearance of the left knee to the right knee
- D. Have the child soak the affected knee in warm water
Correct Answer: C
Rationale: Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (Choice A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (Choice B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (Choice D) is not the priority at this stage as assessing for any physical changes is more crucial.
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct Answer: B
Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.
Which action by a graduate nurse would require the charge nurse to intervene?
- A. Walking in the hallway outside the operating room without a hair covering
- B. Putting on a surgical mask, gown, and cap before entering the operating room
- C. Wearing a surgical mask into the holding area
- D. Wearing scrubs from home into the nursing station
Correct Answer: A
Rationale: The correct answer is walking in the hallway outside the operating room without a hair covering. In healthcare settings, it is crucial to adhere to infection control measures, which include wearing appropriate attire to prevent the spread of pathogens. Walking in the hallway outside the operating room without a hair covering violates these infection control protocols, necessitating immediate intervention by the charge nurse. Choices B and C are incorrect because putting on surgical attire before entering the operating room and wearing a surgical mask into the holding area are both standard practices that promote patient safety and infection control. Choice D is also incorrect as wearing scrubs from home into the nursing station, while not ideal, is not a violation that warrants immediate intervention compared to breaching infection control protocols near sensitive areas like the operating room.
The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?
- A. Set limits and send the client to their room.
- B. Explain to the client that not all people are Christians.
- C. Remove the Bible from the client and explain that they are not "Jesus"?.
- D. Ask the client to share with the group how he knows that he is "Jesus"?.
Correct Answer: A
Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.
The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?
- A. Engage the client to walk with you to make another pot of coffee
- B. Ask the client to reflect on their behavior to determine if it is appropriate
- C. Ask the group to tell the client how they feel when she interrupts
- D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy
Correct Answer: A
Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.