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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. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
- D. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
Correct Answer: C
Rationale: A UAP checking for fecal impaction is outside their scope, requiring immediate reassignment to a nurse.
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The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse-manager?
- A. Contact the healthcare provider to ensure that a prescription for restraints was written.
- B. Advise the staff nurse to remove the restraints from the client's wrists.
- C. Determine if the client has an as needed (PRN) prescription for an antianxiety agent.
- D. Close the door to the room to avoid disturbing other clients in nearby rooms.
Correct Answer: B
Rationale: Removing restraints prioritizes the client's autonomy and safety, avoiding harm from inappropriate use.
The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?
- A. Assume care of the client and assign the PN to the care of a different client.
- B. Acknowledge that the PN has positioned the client safely and correctly.
- C. Arrange for an unlicensed assistive personnel to assist the PN during the procedure.
- D. Demonstrate to the PN how to position the client more effectively for the procedure.
Correct Answer: D
Rationale: Demonstrating proper positioning corrects the error, educates the PN, and ensures client safety during the procedure.
The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?
- A. 30 mL of serous fluid obtained from compression bulb device in last 4 hours.
- B. 40 mL per hour of dark, cloudy urine from urinary catheter in last 4 hours.
- C. 20 mL of serosanguinous drainage from chest tube in last 8 hours.
- D. No observable drainage from 3-day-old Penrose drain in last 8 hours.
Correct Answer: D
Rationale: No drainage from a Penrose drain may indicate obstruction or infection, requiring immediate assessment.
The registered nurse (RN) is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the emergency department (ED) nurse calls to report on a client with unstable angina who must be admitted immediately. A practical nurse (PN) and unlicensed assistive personnel (UAP) are available to the RN. How should the RN assign the necessary nursing actions?
- A. Assign the UAP to prepare the room while the PN obtains report on the new admission and the RN assists with the thoracentesis.
- B. Assign the UAP to assist with the thoracentesis while the PN goes to the ED to transport the client to the unit and the RN obtains report from the ED nurse.
- C. Assign the PN to assist with the thoracentesis while the RN obtains report and the UAP prepares the room for the new admission.
- D. Assign the PN to go to the ED to obtain report and transport the client while the UAP prepares the room and the RN assists with the thoracentesis.
Correct Answer: D
Rationale: The PN can handle report and transport, the UAP can prepare the room, and the RN is needed for the thoracentesis.
The charge nurse is assigning care to clients who are all receiving continuous intravenous medication infusions. The client receiving which medication infusion is best to assign to the licensed practical nurse (PN), rather than an RN?
- A. Nitroprusside sodium, an antihypertensive.
- B. Methotrexate, an antimetabolite chemotherapeutic agent.
- C. Octreotide acetate, an antidiarrheal agent.
- D. Amiodarone hydrochloride, an antiarrhythmic agent.
Correct Answer: C
Rationale: Octreotide infusion is stable and within the PN's scope, unlike high-risk medications requiring RN oversight.