Nokea
The nurse reviews the nursing process with a group of students. Which of the following would demonstrate implementation? Select all that apply.
- A. Performing a sterile dressing change
- B. Interviewing the client about their social determinants
- C. Inputs risk for impaired skin integrity into the care plan
- D. Establishing a peripheral vascular access device
- E. Determining if the prescribed pain medication was effective
Correct Answer: A, D
Rationale: Performing a dressing change (A) and establishing IV access (D) are implementation actions, executing the care plan. Interviewing (B) is assessment, inputting risks (C) is planning, and determining medication effectiveness (E) is evaluation.
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You are the charge nurse on a medical-surgical unit. You have noticed over the last several weeks that one of the nurses on your team is displaying anger and negative feelings, which is not at all characteristic of this experienced nurse. What is this nurse most likely experiencing?
- A. Burnout
- B. Role confusion and dissonance
- C. Ineffective role performance
- D. Fatigue
Correct Answer: A
Rationale: Persistent anger and negative feelings (A) in an experienced nurse suggest burnout, a state of emotional and physical exhaustion from prolonged stress. Role confusion (B), ineffective performance (C), and fatigue (D) may contribute but are less specific to the described emotional changes.
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.
A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
- A. Document the refusal
- B. Notify the primary healthcare provider (PHCP)
- C. Review the client's most recent platelet count
- D. Inquire with the client about the refusal
Correct Answer: D
Rationale: Inquiring about the refusal (D) allows the nurse to understand the client’s concerns, provide education, and address barriers, promoting informed decision-making. Documenting (A) and notifying the provider (B) are secondary steps, and reviewing platelet count (C) is irrelevant without addressing the refusal first.
The nurse is providing discharge instructions to a client who speaks a language different from the nurse's. The client's family members are present, and they speak English. Which action by the nurse is the most appropriate to ensure effective communication during the discharge process?
- A. Use a smartphone translation app to convey the instructions to the client.
- B. Provide written material in the client's language and provide oral instructions in English.
- C. Request an interpreter from the hospital's language services to assist with the discharge instructions.
- D. Summarize the instructions in basic English and have the family members relay the information to the client.
Correct Answer: C
Rationale: Using a professional interpreter (C) ensures accurate communication, adhering to legal and ethical standards for discharge teaching. Smartphone apps (A) are unreliable, written material with English oral instructions (B) is ineffective, and relying on family (D) risks misinterpretation.
The nurse is providing patient care working in a unit that uses the total patient care model for delivering nursing care. The nurse recognizes which of the following as an aspect of this nursing care delivery model?
- A. The RN assumes responsibility for a caseload of patients.
- B. The RN supervises team members providing direct patient care.
- C. The RN provides care for the same patients during their hospital stay.
- D. The RN is responsible for all aspects of care during a shift of care.
Correct Answer: D
Rationale: In the total patient care model, the RN is responsible for all aspects of care for assigned clients during a shift (D). Caseload responsibility (A) and continuity of care (C) are partial aspects, and supervision (B) aligns more with team nursing, not total patient care.