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When triaging emergency room clients, which client should the nurse assess first?
- A. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
- B. A female client with severe right lower abdominal pain who is febrile and vomiting.
- C. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.
- D. A child who has had a cold for two days and now is coughing up green sputum.
Correct Answer: B
Rationale: Severe right lower abdominal pain with fever and vomiting suggests appendicitis, a surgical emergency requiring immediate assessment. Vomiting, leg pain, and green sputum are less urgent conditions.
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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.
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.
Which client requires the most immediate intervention by the nurse?
- A. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).
- B. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: B
Rationale: The client with acute kidney injury and unresponsiveness likely has uremic encephalopathy, a life-threatening condition requiring immediate intervention. The other clients' conditions are less urgent as they are receiving appropriate treatments.
A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?
- A. Obtain the client's legal records for power of attorney.
- B. Give analgesic medications as needed (PRN).
- C. Discontinue the intravenous infusion.
- D. Ask the palliative care team to speak with the client.
Correct Answer: D
Rationale: Consulting palliative care respects the client's wish to avoid machines and provides holistic end-of-life support. Power of attorney, analgesics, and IV discontinuation are secondary or inappropriate.
The nurse determines that an elderly client with pneumonia has a nursing problem of 'altered nutrition, less than body requirements.' Which instruction should the nurse give the unlicensed assistive personnel (UAP) helping with the care of this client?
- A. Offer to assist the client with meal preparation and feeding.
- B. Thicken the client's liquids if aspiration seems likely.
- C. Listen to the client's breath sounds before and after meals.
- D. Assist the client in selecting high protein foods on the menu.
Correct Answer: A
Rationale: Assisting with feeding is within the UAP's scope and addresses the client's nutritional needs. Thickening liquids, listening to breath sounds, and selecting foods require RN judgment.