Nokea
The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply.
- A. Gloves being worn to pass out meal trays
- B. Sterile water used to irrigate nasogastric tubes
- C. Dedicated blood pressure cuffs for clients with contact precautions
- D. Sterile gloves used to provide perineal care during bed baths
- E. New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN)
Correct Answer: A, D
Rationale: Wearing gloves for meal tray distribution (A) and sterile gloves for perineal care (D) are excessive, as non-sterile gloves suffice, wasting resources. Sterile water for NG irrigation (B), dedicated cuffs for precautions (C), and new IV tubing for TPN (E) are appropriate practices.
You may also like to solve these questions
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. has atrial fibrillation and a heart rate of 112/minute.
- B. has glomerulonephritis with a blood pressure of 137/86 mm Hg.
- C. is receiving amphotericin B, and the most recent temperature is 100.4°F (38°C).
- D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
Correct Answer: A
Rationale: Atrial fibrillation with a heart rate of 112/minute (A) indicates a rapid ventricular response, risking hemodynamic instability or stroke, requiring immediate rate control. Glomerulonephritis with normal BP (B), mild fever with amphotericin (C), and COPD with 91% saturation (D) are less urgent, as they are stable or expected.
The nurse working in the emergency department is caring for a client with carbon monoxide poisoning. Which of the following would be the priority action to treat this condition?
- A. Initiate continuous pulse oximetry monitoring
- B. Administer high-flow oxygen
- C. Insert a peripheral vascular access device
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: B
Rationale: High-flow oxygen (B) is the priority for carbon monoxide poisoning to displace CO from hemoglobin, per ACLS guidelines. Pulse oximetry (A) is unreliable in CO poisoning, IV access (C) and ECG (D) are secondary to oxygenation.
During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP). Which of the following is the nurse's primary responsibility?
- A. Document the completion of the task.
- B. Make a list of tasks not yet completed to pass on to the next shift.
- C. Observe the UAP for the duration of the task.
- D. Follow-up with the UAP to ensure completion of the task and evaluate the outcome.
Correct Answer: D
Rationale: The nurse’s primary responsibility is to follow up with the UAP (D) to ensure tasks are completed correctly and evaluate outcomes, maintaining accountability for delegated care. Documentation (A), listing incomplete tasks (B), and continuous observation (C) are not primary responsibilities.
The nurse is triaging phone calls at a clinic. The nurse should initially follow-up with the client who reports
- A. decreased libido while receiving prescribed dutasteride.
- B. swelling in their right leg while receiving prescribed tamoxifen.
- C. hot flashes and night sweats while receiving prescribed letrozole.
- D. bone pain while receiving prescribed filgrastim.
Correct Answer: B
Rationale: Right leg swelling on tamoxifen (B) suggests deep vein thrombosis, a life-threatening emergency requiring immediate follow-up. Decreased libido (A), hot flashes (C), and bone pain (D) are expected side effects and less urgent.
The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle?
- A. Autonomy
- B. Justice
- C. Paternalism
- D. Veracity
Correct Answer: A
Rationale: Informed consent demonstrates autonomy (A), allowing the client to make self-determined decisions, per ethical principles. Justice (B) ensures fairness, paternalism (C) involves decision-making for the client, and veracity (D) is truth-telling, none central to consent.