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The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse manager?
- A. Contact the healthcare provider to ensure that a prescription for restraints was written.
- B. Advise the staff nurse to remove the restraints from the client's wrists.
- C. Close the door to the room to avoid disturbing other clients in nearby rooms.
- D. Determine if the client has an as needed (PRN) prescription for an antianxiety agent
Correct Answer: B
Rationale: Removing restraints is the priority as they are unjustified for staff convenience and violate client rights. Checking for a prescription, closing the door, or considering antianxiety medication do not address the immediate ethical and safety concerns.
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A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?
- A. Obtain the client's legal records for power of attorney.
- B. Give analgesic medications as needed (PRN).
- C. Discontinue the intravenous infusion.
- D. Ask the palliative care team to speak with the client.
Correct Answer: D
Rationale: Consulting palliative care respects the client's wish to avoid machines and provides holistic end-of-life support. Power of attorney, analgesics, and IV discontinuation are secondary or inappropriate.
The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?
- A. The acuity level of the clients on the unit.
- B. The physicians' plans to perform procedures on the unit.
- C. The number of clients leaving the unit for diagnostic tests.
- D. The skill level of the personnel staffing the unit.
Correct Answer: A
Rationale: Client acuity determines the intensity of care needed, directly impacting staffing requirements. Procedures, diagnostic tests, and staff skills are secondary considerations.
An older female client who was recently widowed has become increasingly confused and disoriented. Her family tells the healthcare provider's office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed healthcare plan. Which information is best for the nurse to provide this family?
- A. Managed healthcare plans do not pay for any in-hospital medical evaluations.
- B. Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital.
- C. The client is grieving normally in response to her husband's death and hospitalization is not necessary.
- D. Managed care providers have mandatory pre-certification requirements for hospitalization.
Correct Answer: D
Rationale: Informing about pre-certification requirements is factual and guides the family on necessary steps for hospitalization. Other options are inaccurate, insensitive, or dismissive of the client's medical needs.
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
- A. Notify the healthcare provider.
- B. Monitor for signs of bleeding.
- C. Complete an adverse occurrence report.
- D. Obtain blood for coagulation studies.
Correct Answer: A
Rationale: Notifying the healthcare provider ensures prompt intervention to reverse anticoagulation and prevent bleeding. Monitoring, reporting, and testing are important but follow provider notification.
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
- B. Heparin in Normal Saline prescribed for deep vein thrombosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Regular insulin in Normal Saline prescribed for ketoacidosis.
Correct Answer: A
Rationale: Ceftriaxone can be safely administered by gravity infusion with nurse monitoring, as its dosing is less sensitive to minor flow rate variations. Heparin, magnesium, and insulin require precise infusion rates due to risks of bleeding, toxicity, or glucose imbalances, necessitating an IV pump.