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Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
- A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.
- B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
- C. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
- D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
Correct Answer: D
Rationale: Checking for fecal impaction is beyond the UAP's scope, risking client injury. The other assignments (transport, BP monitoring, blood retrieval) are within the respective staff's competencies.
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Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?
- A. Announce the new plan at a special employee wellness event.
- B. Determine staff opinion of current healthcare insurance costs.
- C. Survey the nurses to see who wants to keep the old benefits plan.
- D. Be available to all shifts to discuss the changes in health benefits.
Correct Answer: D
Rationale: Being available to discuss changes ensures clear communication and addresses concerns across all shifts, fostering acceptance. Announcing at an event, assessing current costs, or surveying preferences are less critical post-approval.
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.
The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
- A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
- B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
- C. Renal transplant yesterday, complaining of flank pain and who states, 'it's hot in here.'
- D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?
- A. The client two days post-thyroidectomy and is unable to speak clearly due to laryngeal nerve damage.
- B. The client newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine.
- C. The client with diabetes and has an elevated serum glycosylated Hgb (Hgb A1C).
- D. The client exhibiting signs of Addison's crisis after corticosteroids were discontinued.
Correct Answer: A
Rationale: Laryngeal nerve damage post-thyroidectomy risks airway obstruction, requiring RN monitoring. Hypothyroidism, diabetes, and Addison's crisis can be managed by a PN under supervision.
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control. Play time, parent instruction, and room assignment are secondary.