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The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
- A. A client who had an abdominal-perineal resection 3 days ago has no drainage on the dressing and is reporting chills.
- B. A client who fell from a ladder and has a collapsed left lower lung with 100 mL drainage in a chest tube collection container.
- C. A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm-sized dark red drainage.
- D. A client who is post-mastectomy 2 days ago and has 50 mL of serosanguineous fluid in a Jackson-Pratt drain.
Correct Answer: A
Rationale: The client with no drainage and chills may have an infection or sepsis, which are life-threatening complications requiring immediate assessment and physician notification. The chest tube drainage is normal, the gunshot wound drainage is not excessive, and the mastectomy drain output is expected, making these less urgent.
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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.
The smell of cigarette smoke is coming from a client's bathroom. Which action should the nurse implement first?
- A. Document the occurrence in the client's record.
- B. Obtain a prescription for a nicotine patch during hospitalization.
- C. Educate the client about the hospital smoking policy.
- D. Notify the charge nurse about the situation immediately.
Correct Answer: D
Rationale: Notifying the charge nurse ensures immediate enforcement of the no-smoking policy to prevent fire risks. Documenting, prescribing patches, or educating are secondary actions.
In evaluating a staff nurse who demonstrates inconsistent performance, which intervention should the nurse- manager employ?
- A. Evaluate the nurse's performance using standards of practice, citing both strengths and weaknesses with emphasis on ways to improve practice.
- B. Focus on the strengths of the staff nurse; discuss any weaknesses verbally but avoid documenting the nurse's negative behaviors.
- C. Emphasize the nurse's areas of weakness in light of the inconsistent performance observed and discuss how to improve in each of these areas.
- D. Focus on a discussion of how the inconsistency in the staff nurse's performance disrupts the routine of all of the staff members on the unit.
Correct Answer: A
Rationale: Evaluating using standards provides objective feedback, balancing strengths and weaknesses to guide improvement. Focusing only on strengths or weaknesses, or discussing team disruption, may demotivate or fail to address performance issues effectively.
To help prevent by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will
- A. demonstrate how to complete an adverse occurrence or variance report.
- B. discuss how to handle complaints from clients and/or their families.
- C. describe how to obtain legal services if needed.
- D. maintain personal malpractice insurance.
Correct Answer: B
Rationale: Teaching nurses to handle complaints effectively can prevent escalation to litigation by resolving conflicts early. Completing variance reports, obtaining legal services, or maintaining insurance are important but less preventive than addressing complaints directly.
A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?
- A. Caution the nurse that one more tardiness will result in probational employment.
- B. Offer to switch the nurse's shift assignments to afternoons or evenings.
- C. Stress the expectation that the nurse will arrive on time for all scheduled shifts.
- D. Have the nurse sign a copy of the hospital employee attendance policy.
Correct Answer: C
Rationale: Stressing punctuality expectations communicates the importance of timeliness clearly and respectfully. Threatening probation is overly punitive, changing shifts may not solve the issue, and signing a policy is less effective than direct communication.