Nokea
The nurse manager receives a complaint from a client's family member. The nurse manager should take which initial action?
- A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately
- B. Speak with the night shift nurse regarding the complaint and discuss the care provided
- C. Assess the complaint and clarify the details with the family member and client
- D. Take note of the complaint and place it in the applicable employee's file
Correct Answer: C
Rationale: Assessing the complaint and clarifying details with the family and client (C) is the initial step to understand the issue and ensure accurate resolution. Directing the charge nurse (A), speaking with the nurse (B), or filing the complaint (D) are premature without first gathering facts.
You may also like to solve these questions
The emergency department (ED) nurse is assigned clients with assigned clients. Place the actions in the order of priority, starting with the highest priority.
- A. Dress a wound for a client discharged with multiple lacerations to the right arm.
- B. Insert a peripheral vascular access device for a client with mild dehydration and infuse prescribed fluids.
- C. Assess a client’s blood pressure who is receiving an infusion of dopamine.
- D. Witness informed consent for a client scheduled for surgery in six hours.
- E. Administer prescribed magnesium sulfate infusion for a client with status asthmaticus.
Correct Answer: C, E, B, D, A
Rationale: Assessing BP on dopamine (C) ensures hemodynamic stability, followed by magnesium for status asthmaticus (E) to control life-threatening bronchospasm. IV access for dehydration (B), informed consent (D), and wound dressing (A) are less urgent, as they address stable or non-emergent needs.
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit.
- A. Levofloxacin 750 mg IVPB Q12 hours
- B. 0.9% Saline 125 ml/hr
- C. Metoclopramide 10 mg IV Push Q8 hours
- D. Ketorolac 15 mg IV Push Q8 hours
Correct Answer: A
Rationale: Pneumonia in an elderly client can be particularly severe due to age-related immune system decline and potential for complications like acute respiratory distress syndrome (ARDS) and/or sepsis.
The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply.
- A. drawing a line through the erroneous documentation.
- B. using correction tape and write over the error.
- C. writing over the error in darker ink.
- D. completely black out the error with a black marker.
- E. discarding the documentation in the trash and starting over.
- F. writing your initials, date, and time above the erroneous documentation with the word 'error.'
Correct Answer: A, F
Rationale: Correcting documentation errors involves drawing a single line through the error (A) and initialing, dating, and noting 'error' (F). Correction tape (B), writing over (C), blacking out (D), or discarding (E) are incorrect and violate documentation standards.