Nokea
The Unlicensed Assistive Personnel (UAP) is helping a female patient with early ambulation postsurgery. The CNA has just applied a gait belt to the patient's waist. Which of the following actions by the CNA will need interference and correction by the supervising nurse?
- A. Holding onto the belt's outer edge or center, preventing the patient from leaning or drooping to one side.
- B. Pulling from the front of the belt, keeping forward momentum.
- C. Bringing the client to a nearby chair when she feels dizzy.
- D. Keeping the patient's body weight close to her own.
Correct Answer: B
Rationale: Pulling from the front of the gait belt (B) risks causing the client to lose balance or fall, requiring correction. Holding the belt (A), seating a dizzy client (C), and maintaining close body alignment (D) are appropriate and safe actions.
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When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward?
- A. Report the conflict to the director of nursing over the unit.
- B. Report the conflict to the nurse manager of the unit.
- C. Report the conflict to the assigned charge nurse of the unit.
- D. Discuss the conflict with another nurse to attempt resolution of the issue.
Correct Answer: B
Rationale: Reporting to the nurse manager (B) follows the chain of command for unresolved conflict, ensuring appropriate resolution. The director (A) is too high, the charge nurse (C) may lack authority, and discussing with another nurse (D) risks gossip and unprofessionalism.
The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.
The nurse is providing a handoff report to a nurse in the critical care unit. The nurse states that it would be helpful for the primary healthcare provider (PHCP) to refer the client to a support group upon discharge. This statement represents which part of the ISBAR handoff report?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: D
Rationale: Suggesting a support group referral (D) is a recommendation, part of the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) handoff, proposing actions for ongoing care. It is not situation (A), background (B), or assessment (C).
You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children?
- A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.
- B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof.
- C. The cognitive development of young children impacts their understanding of death.
- D. The cognitive development of young children before 12 has no impact on their understanding of death
Correct Answer: C
Rationale: Cognitive development (C) influences how children, like the 8-year-old, understand death. Younger children may view death as reversible or temporary, while adolescents, like the 14-year-old, grasp its finality. Tailoring explanations to their developmental stage is essential. Options A and B are incorrect as children do have perspectives, and avoiding discussion (A) is unhelpful. Option D contradicts developmental psychology.
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.