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The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to implement initially?
- A. Reassign the coworker to the care of clients not receiving opioids.
- B. Notify the primary health care provider that the client needs an increase in opioid dosage.
- C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor.
- D. Confront the coworker with the information about the client having pain control problems and ask if the coworker is using the opioids personally.
Correct Answer: C
Rationale: In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. To reassign the coworker to clients not receiving opioids ignores the issue. The client does not need an increase in opioids. A confrontation is not the most advisable action because it could result in an argumentative situation.
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A hospital administrator has implemented a change in the method of assigning nurses to client care units. A group of registered nurses is resistant to the change, and the nursing administrator anticipates that the nurses will not facilitate the process of change. Which approach is best for the administrator to take initially in dealing with the resistance?
- A. Cancel the implementation of the change.
- B. Implement the change first on a trial basis.
- C. Delay implementing the change for a few weeks.
- D. Encourage the nurses to verbalize feelings regarding the change.
Correct Answer: D
Rationale: Face-to-face meetings to address the issue at hand will allow verbalization of feelings, identification of problems and issues, and the development of strategies to solve the problem. Option 1 will not address the problem. Option 2 is not the initial intervention. Option 3 may provide a temporary solution to the resistance but will not specifically address the concern.
In the middle of bathing a client, the unit secretary notifies the nurse that there is an emergency telephone call. Which action should the nurse implement to best assure client safety?
- A. Quickly finish the bath before answering the call.
- B. Immediately leave the client's room and answer the call.
- C. Cover the client, place the call light within reach, and then leave to answer the call.
- D. Leave the door open and ask staff to monitor the client, and then leave to answer the call.
Correct Answer: C
Rationale: Because the telephone call is an emergency, the nurse may need to answer it. To maintain privacy and safety, the nurse covers the client and places the call light within the client's reach. Additionally, the client's door should be closed or the room curtains pulled around the bathing area. The other appropriate action is to ask another nurse to accept the call. This, however, is not one of the options. None of the other options effectively meet the client's safety needs.
An older client had an open reduction with internal fixation (ORIF) for a hip fracture 4 days ago. Which measure should the nurse implement to provide safe care?
- A. Provide ice chips instead of drinking water.
- B. Instruct the client to call for help before getting up.
- C. Minimize opioid administration to prevent dizziness.
- D. Tell the client to roll to the affected side first before getting up.
Correct Answer: B
Rationale: The nurse instructs the client to call for help before getting up because the client has multiple risk factors for falls, is of older age, has postoperative status, and may also be receiving opioid analgesia. Restricting fluid intake with ice chips is not indicated; besides, adequate hydration is important for maintaining cardiac output and renal function, for keeping respiratory secretions thin, and in preventing constipation. The nurse administers opioid analgesics as indicated and fulfills the nurse's duty owed to the client by acting to resolve pain. The nurse instructs the client to roll to the unaffected side to get up to prevent excessive stress on the fragile surgical wound.
The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions should the nurse implement for this client?
- A. Enteric precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: C
Rationale: Contact precautions include standard precautions and require the use of barrier precautions such as gloves and goggles. Contact precautions are used for clients who have diarrhea, draining wounds, or methicillin-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through inanimate objects or surfaces that the pathogen has contaminated, such as instruments, linens, dressing materials, or hands. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Droplet and airborne precautions are used if the organism is transmitted via the respiratory tract.
A registered nurse is delegating activities to the nursing staff. Which activities can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply.
- A. Collecting a urine specimen from a client
- B. Obtaining frequent oral temperatures on a client
- C. Assessing a client who returned from the recovery room 6 hours ago
- D. Assisting a post-cardiac catheterization client who needs to lie flat to eat lunch
- E. Accompanying a client being discharged to meet his spouse at the hospital exit door
Correct Answer: A,B,D,E
Rationale: Unlicensed assistive personnel (UAP) are trained to perform noninvasive tasks and those that meet basic client needs, such as collecting specimens, taking vital signs, assisting with activities of daily living, and escorting clients. Therefore, collecting a urine specimen, obtaining frequent oral temperatures, assisting a post-cardiac catheterization client to eat lunch while lying flat, and accompanying a client to the hospital exit are appropriate tasks for the UAP. Assessing a client who returned from the recovery room requires clinical judgment and is a task for a licensed nurse, as it involves evaluating the client's condition and identifying potential complications.