Nokea
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.
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An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100°F (37.8°C), blood pressure 98/50 mm Hg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Replace fluids intravenously based on intake and output.
- B. Record the amount of daily wound drainage.
- C. Assess skin condition and turgor for breakdown.
- D. Turn every 2 hours around the clock from side-to-side.
Correct Answer: A
Rationale: IV fluid replacement addresses hypovolemia and prevents shock, critical given the client's vital signs. Recording drainage, assessing skin, and turning are important but secondary to stabilizing fluid status.
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.
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?
- A. Begin initial sterile wound care for surgical clients.
- B. Validate prescribed intravenous flow rates.
- C. Determine the need for urinary catheterizations.
- D. Receive a postoperative client and conduct the assessment.
Correct Answer: B
Rationale: Validating IV flow rates is within the PN's scope, involving routine checks of orders and drip rates. Initial wound care, assessing catheter need, and postoperative assessments require RN clinical judgment.
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.
During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe an as needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. Which instruction should the nurse provide the unit clerk?
- A. Remain with this client and monitor the vital signs while the nurse takes the call.
- B. Ask the healthcare provider to remain on 'hold' until the nurse can confirm the prescription.
- C. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.
- D. Tell the healthcare provider the nurse will return the phone call as soon as possible.
Correct Answer: D
Rationale: The unit clerk cannot take verbal orders; instructing the provider to be called back ensures the nurse handles the prescription directly. Monitoring vitals, holding the call, or writing orders are inappropriate for the clerk's role.