Nokea
The nurse notices an unlicensed assistive personnel (UAP) passing by several call lights during the shift. Which initial action should the nurse take?
- A. Approach the UAP about the behavior.
- B. Report unsafe behavior to the charge nurse.
- C. File an incident report due to safety risk.
- D. Ask another UAP to help cover this UAP's patient load.
Correct Answer: B
Rationale: Approaching the UAP (B) initially allows for clarification and correction of the nurse can address the behavior, promoting teamwork and addressing potential safety issues.. Reporting to the charge nurse (A) or filing an incident report (C) escalates prematurely. Assigning another UAP (D) does not address the root cause.
You may also like to solve these questions
The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.
- A. He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
- B. His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
- C. Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
- D. Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
- E. I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.
Correct Answer: E, C, A, B, D
Rationale: Using ISBAR: 1. Identification (E) introduces the nurse and client. 2. Situation (C) outlines the current issue (chest pain, dyspnea). 3. Background (A) provides history. 4. Assessment (B) details vital signs and findings. 5. Recommendation (D) includes transfer orders and next steps.
The nurse is caring for a client who is postoperative following a lobectomy. The client is receiving fentanyl via an epidural. The nurse should monitor the client for which complication?
- A. Diarrhea
- B. Hypotension
- C. Hyperventilation
- D. Urinary incontinence
Correct Answer: B
Rationale: Epidural fentanyl can cause hypotension (B) due to vasodilation, a serious complication requiring monitoring. Diarrhea (A), hyperventilation (C), and urinary incontinence (D) are less common or unrelated.
The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client
- A. with a chest tube that has tidaling in the water seal chamber.
- B. that is receiving mechanical ventilation and is occasionally biting on the tube.
- C. that is receiving albuterol via a nebulizer and reports headache and nervousness.
- D. with pneumonia that has become restless and confused.
Correct Answer: D
Rationale: Restlessness and confusion in pneumonia (D) suggest hypoxia or worsening infection, requiring immediate follow-up to prevent deterioration. Chest tube tidaling (A) is normal, tube biting (B) is concerning but less acute, and albuterol side effects (C) are expected.
A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action?
- A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms.
- B. Ensure that a working IV pump is set up at the patient's bedside.
- C. Order a STAT arterial blood gas (ABG).
- D. Pad the side rails of the patient's assigned bed.
Correct Answer: D
Rationale: Padding the side rails (D) is the priority to prevent injury during ongoing or recurrent seizures in alcohol withdrawal, ensuring immediate safety. Requesting clonazepam (A) requires a physician order and is secondary, IV pump setup (B) is not urgent unless medication is ordered, and ABG (C) is unnecessary unless respiratory distress is present.
The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a
- A. collaborator
- B. team leader
- C. delegator
- D. manager
Correct Answer: A
Rationale: Collaborating with others across settings to achieve client-centered goals (A) defines the nurse’s role as a collaborator. Team leader (B) focuses on directing a group, delegator (C) assigns tasks, and manager (D) oversees operations, none of which fully capture this role.