Nokea
Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?
- A. Wearing clean gloves while performing a heel stick on an infant
- B. Wearing the same gloves for assessments of clients in the same room
- C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
- D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus
Correct Answer: A
Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.
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The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?
- A. Keep NPO and hold medication.
- B. Hold sedatives, but allow the client to have breakfast and give other medicines.
- C. Administer medications, but hold anticonvulsants.
- D. Give additional fluids and some caffeine prior to the test.
Correct Answer: C
Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.
The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best?
- A. Call the staff nurse in and place them on a work improvement plan after a 3-day suspension
- B. Have the other staff gather additional information on the tardy staff member
- C. Call the staff nurse in for an interview to investigate the problem and possible solutions
- D. Assign a mentor to assist the staff member in arriving on time
Correct Answer: C
Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems. Choice A is incorrect as it immediately involves suspension without investigation or support. Choice B is not the best course of action as it does not involve direct communication with the staff member in question. Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.
The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?
- A. Nasal congestion
- B. Hiccups
- C. Blood glucose of 150
- D. Muscle spasms
Correct Answer: D
Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.
While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?
- A. Remove the client from the room immediately.
- B. Leave the client's room to obtain a fire extinguisher.
- C. Instruct a nurse tech to pull the fire alarm.
- D. Evacuate all clients from the unit.
Correct Answer: A
Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.
The power a healthcare professional exerts when working to accomplish goals and effect change in an agency or policy is considered what type of power?
- A. political
- B. personal
- C. positional
- D. professional
Correct Answer: A
Rationale: Political power is the correct answer in this scenario. It stems from the ability to navigate systems, agencies, or policies to bring about change. Personal power is related to charisma and self-confidence in informal leadership roles. Positional power comes from holding a specific authority in a formal position. Professional power is derived from expertise in a particular area of practice. Therefore, in the context of effecting change in an agency or policy, political power is the most relevant type of power.