The nurse is caring for a 14-year-old scheduled for an appendectomy. What is the nurse's role in obtaining informed consent before surgery? Select all that apply.
Rationale:
C: Validate that the parents are competent to provide consent for the client. The nurse's role includes ensuring that the parents possess the necessary capacity to comprehend the surgical information and make informed decisions regarding their child's care.
A: Informing the parents that only the surgeon may withdraw the surgical consent. This statement misrepresents the collaborative nature of consent; other healthcare providers may also have input on consent matters.
B: Review the risks and benefits of the surgery with the parents. While important, this task typically falls under the surgeon's responsibilities to provide detailed information about the procedure and its implications.
E: Make sure that the consent is witnessed by two healthcare professionals instead of one. Protocols usually require only one witness for the informed consent, making this requirement unnecessarily stringent and unusual in most settings.
The nurse notices an unlicensed assistive personnel (UAP) passing by several call lights during the shift. Which initial action should the nurse take?
Rationale:
B: Reporting unsafe behavior to the charge nurse is essential to ensure patient safety and proper staffing. This action will prompt immediate investigation and corrective measures, addressing the UAP's negligence effectively.
A: Approach the UAP about the behavior. Directly confronting the UAP may not lead to immediate resolution or accountability, and could cause defensiveness, undermining a professional response to the issue.
C: File an incident report due to safety risk. While documenting safety concerns is important, the immediate priority should be addressing the behavior with supervisory support to ensure prompt corrective action.
D: Ask another UAP to help cover this UAP's patient load. Assigning additional help does not address the underlying issue of negligence and may perpetuate unsafe practices among staff, compromising patient care.
A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action?
Rationale:
D: Pad the side rails of the patient's assigned bed.
During alcohol withdrawal, patients are at increased risk for seizures, which can lead to falls and injuries. Padding the side rails ensures safety by minimizing the risk of harm during potential seizure activity.
A: Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms.
While clonazepam can aid in managing withdrawal symptoms, immediate safety measures like padding side rails take precedence to prevent injury during potential seizures.
B: Ensure that a working IV pump is set up at the patient's bedside.
Setting up an IV pump is important for medication administration but does not directly address the immediate safety concerns posed by the risk of seizures.
C: Order a STAT arterial blood gas (ABG).
Ordering an ABG may provide valuable information but does not contribute to the immediate safety and injury prevention needed for a patient experiencing withdrawal seizures.
The nurse has attended a staff education program about incident reporting. It would indicate effective understanding if the nurse states that the primary purpose of incident reporting is to
Rationale:
The primary purpose of incident reporting is to implement corrective measures needed to prevent recurrence.
Effective incident reporting focuses on identifying areas for improvement and preventing future occurrences, emphasizing the importance of learning from mistakes to enhance patient safety and care quality within healthcare settings.
B: Collect data about errors and compare it to different time periods. This option overlooks the primary focus on immediate corrective action rather than merely analyzing historical error data.
C: Communicate the error(s) to other departments within the facility. While communication is important, it does not address the essential goal of preventing future incidents through corrective actions.
D: Notify the individual involved of the deviation from the standard of care. This option centers on individual notification rather than the broader objective of systemic improvement to prevent recurrences.
The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
B
His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
C
Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
D
Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
E
I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.
Rationale:
I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome. This introduction sets the stage for effective communication, ensuring the receiving nurse understands the caller's identity and the reason for the report.
A: He is a 56-year-old male admitted two days ago with community-acquired pneumonia. This information provides background but lacks urgency about the current cardiac condition requiring immediate attention.
B: His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. While vital signs are critical, this detail should follow initial identification and situational context to ensure clarity.
C: Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin. Although this provides situational information, it lacks comprehensive background and assessment details necessary for effective handoff.
D: Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. This recommendation is essential but should be communicated last, following all pertinent identification, situation, background, and assessment details.
An advantage of mutual pretense at the end of life for the client is that it allows the client:
Rationale:
To preserve a degree of dignity and privacy at the end of life.
Mutual pretense allows clients to maintain a sense of control over their situation, fostering an environment where they can confront their mortality with dignity while shielding intimate emotions from loved ones, thereby enhancing the quality of their final moments.
A: To fully employ the ego defense mechanism of denial at the end of life. Denial may provide temporary relief, but it detracts from authentic engagement with reality and can hinder meaningful connections.
B: To exercise control over loved ones when they are at the end of life. Exercising control over loved ones can create tension and hinder genuine emotional exchanges, ultimately detracting from mutual support.
C: To fully employ the ego defense mechanism of projection at the end of life. Projection misplaces one’s feelings onto others, which obstructs genuine communication and emotional understanding during such a critical life phase.
The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
Rationale:
A: yellow tag. The yellow tag indicates a client who requires urgent care but is not in immediate life-threatening condition. The client's responsiveness and vital signs suggest they need timely intervention without being critical.
B: red tag. A red tag signifies life-threatening conditions requiring immediate attention. The client's stable capillary refill and respiratory rate indicate they are not in an immediate crisis.
C: black tag. The black tag is reserved for patients who are deceased or have injuries incompatible with life. The client’s responsiveness and vital signs do not warrant this classification.
D: green tag. A green tag denotes minor injuries that can wait for treatment. The client's inability to walk and elevated respiratory rate suggest more significant needs than can be classified as minor.
The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up?
Rationale:
Nausea and vomiting
These symptoms indicate potential worsening of the client’s condition, possibly leading to complications such as aspiration or further metabolic disturbances. In the context of diabetic ketoacidosis, immediate assessment and intervention are vital to prevent deterioration and ensure proper management of the client's health status.
A: Pulse 112/minute Elevated pulse may indicate dehydration or stress, but it is a common response in DKA and not as urgent as nausea and vomiting.
C: Respiratory rate 21/minute A slightly elevated respiratory rate can occur in DKA due to compensatory mechanisms, but it does not signify an immediate life-threatening concern like nausea and vomiting.
D: Blood glucose 299 mg/dL (16.5 mmol/L) This glucose level indicates hyperglycemia, which is expected in DKA, and while it requires monitoring, it does not necessitate immediate follow-up like nausea and vomiting do.
Which statement about the placebo is the most accurate?
Rationale:
Placebo use is unethical unless they are used in research with the subject's consent. Informed consent ensures that participants are aware of the potential use of placebos, aligning with ethical guidelines in medical research. This respect for autonomy is crucial for maintaining trust and integrity between healthcare providers and patients.
A: Placebos are often used to determine if the client's reports of pain are valid. This statement oversimplifies the role of placebos, which primarily serve to assess treatment efficacy rather than validate patient reports.
B: Placebos are not used in research because the client has not given consent. Consent is essential for ethical research; however, placebos can still be utilized if participants are informed appropriately about their use.
D: Placebo use is illegal according to all states and the federal government. Legal status varies; many jurisdictions allow placebos in specific contexts, particularly within clinical trials where ethical guidelines are followed.
The nurse performs a handoff report to the oncoming nurse for an older adult male in the intensive care unit (ICU). Which information is a priority to share with the oncoming nurse? The client
Rationale:
B: The client is forgetful and was not requesting assistance before getting out of bed. This information is critical as it indicates a potential safety risk for falls, highlighting the need for vigilant monitoring and support from the nursing staff. Ensuring the patient’s safety is paramount in an intensive care setting where risks are elevated.
A: has clear lung fields bilaterally with unlabored respirations. While respiratory status is important, it is stable, making it less urgent than the client’s cognitive state and risk of falls.
C: has a 20-gauge peripheral vascular access device that is patent and saline locked. This detail is relevant but routine; it does not pose an immediate risk to the patient’s safety compared to cognitive issues.
D: has an indwelling urinary catheter that is patent with clear urine and is secured to the upper thigh. Although this information is pertinent for infection control, it does not address potential safety concerns linked to the client's forgetfulness.
The nurse in the emergency department (ED) is caring for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially
Rationale:
B: Inserting a peripheral vascular access device is crucial for the client who has overdosed on lithium, as it allows for the administration of fluids, medications, and potential antidotes in an emergency setting.
A: Developing a therapeutic rapport with the client focuses on emotional connection rather than immediate medical intervention, which is not the priority in acute overdose situations.
C: Obtaining the client’s vital signs, while important, does not address the immediate need for intravenous access to manage the overdose effectively.
D: Collecting a serum lithium level can provide information but is secondary to ensuring the client has stable access for urgent treatment and interventions.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN?
Rationale:
A client requiring assistance picking out low potassium foods. This task is suitable for an LPN since it involves basic dietary education and client support, which falls within their scope of practice and training.
B: A client requesting to leave the facility against medical advice (AMA) involves complex legal and ethical considerations, requiring an RN’s expertise to ensure informed consent and safety.
C: A client needing several prescriptions called into the local pharmacy necessitates thorough assessment and clinical judgment, tasks that are typically reserved for RNs due to their advanced training.
D: A client requesting breakthrough intravenous push (IV) pain medicine requires specialized skills and knowledge about medications and patient assessment, which are beyond the scope of an LPN's practice.
The nurse is caring for a client who fell at an outdoor park. On assessment, the client is unconscious and does not have a pulse. The nurse should initially
Rationale:
Begin chest compressions.
Initiating chest compressions is crucial in this scenario as the client is unconscious and pulseless. Immediate action is necessary to maintain blood circulation and oxygen delivery to vital organs, aligning with CPR protocols.
A: Provide two rescue breaths. Administering breaths is not the first step when a pulse is absent; chest compressions should take precedence to restore circulation before addressing ventilation.
C: Assess the client to determine if they are wearing any emergency alert tag(s). Evaluating for emergency tags delays lifesaving interventions, which are critical in a cardiac arrest situation requiring rapid response.
D: Ask another health care professional to check the carotid pulse. Seeking assistance for pulse evaluation prolongs the response time; decisive, immediate action is essential in a cardiac emergency.
The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client
Rationale:
D: with pneumonia that has become restless and confused. This client exhibits signs of potential hypoxia or worsening respiratory status, necessitating immediate assessment and intervention to ensure safety and effective treatment.
A: with a chest tube that has tidaling in the water seal chamber. Tidaling is a normal finding in chest tubes, indicating that the system is functioning properly and does not require urgent intervention.
B: that is receiving mechanical ventilation and is occasionally biting on the tube. Although biting on the tube is concerning, it does not present an immediate life-threatening situation compared to the other clients.
C: that is receiving albuterol via a nebulizer and reports headache and nervousness. While these side effects are noteworthy, they are relatively common and not as critical as the client's confusion and restlessness in option D.
The nurse is planning a staff education program about conflict resolution strategies. It is appropriate for the nurse to identify that compromising in a conflict may result in
Rationale:
Compromising in a conflict may result in incomplete satisfaction of both parties' concerns. This approach seeks a middle ground, often leading to neither party fully achieving their objectives, which can create lingering issues.
B: appeasing an individual by self-sacrificing. Compromising does not inherently involve self-sacrifice; rather, it focuses on finding a mutual agreement that respects both parties' needs and interests.
C: suppression of thoughts and feelings. Compromise encourages open dialogue, allowing for expression rather than suppression. Participants are motivated to share their concerns to reach a collaborative resolution.
D: satisfaction of an individual’s interest regardless of the impact on others. Compromising balances interests, ensuring that the needs of all parties are considered; it does not prioritize one individual over others.
The nurse is caring for a client with suspected sepsis. After reviewing the client's vital signs, which prescription by the primary healthcare provider (PHCP) should the nurse administer first? See the images below.
Rationale:
D: 0.9% sodium chloride (normal saline) bolus. Administering normal saline bolus is critical in sepsis management for rapid volume resuscitation, which helps restore adequate circulation and organ perfusion, addressing hypotension and preventing further complications.
A: Ceftriaxone. While ceftriaxone is an important antibiotic for treating infections, it does not address the immediate need for fluid resuscitation in septic clients.
B: Doxycycline. Doxycycline may be effective for certain bacterial infections, but it lacks the urgency required for initial treatment in suspected sepsis, where fluid resuscitation is paramount.
C: Acetaminophen. Although acetaminophen can reduce fever and discomfort, it fails to tackle the urgent need for fluid replacement, which is essential in managing sepsis effectively.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? Select all that apply. A client
Rationale:
A: A client newly diagnosed with type II diabetes mellitus. This client requires comprehensive education and assessment, tasks that the RN is best equipped to handle due to their advanced training.
B: A client requiring sterile dressing changes to an infected wound. This task falls within the LPN's scope of practice, as they can perform basic wound care under supervision.
C: A client who requires enteral feedings and tracheostomy care. While LPNs can assist with these tasks, the complexity and potential complications warrant an RN’s involvement for optimal patient safety.
E: A client who is two days post-operative following a mastectomy. Post-operative care can be managed by LPNs, making this assignment suitable for them rather than the RN.
F: A client receiving intravenous nitroglycerin for acute coronary syndrome. This critical situation necessitates continuous monitoring and advanced clinical judgment, which is within the RN's purview.
The nurse overhears an unlicensed assistive personnel (UAP) shout at a client, 'you will have to get a feeding tube if you do not start eating more at mealtimes.' The nurse recognizes that the UAP has Select all that apply.
Rationale:
The UAP engaged in unprofessional conduct and committed assault. Shouting at a client not only violates professional standards but also instills fear, which constitutes an aggressive act toward the individual.
A: committed battery. Battery involves physical harm or offensive contact, neither of which occurred in this verbal altercation. No physical injury or unpermitted touching took place.
D: been negligent. Negligence entails a failure to provide appropriate care, which does not apply here as the UAP's actions were intentional and aggressive rather than a lack of attention.
E: demonstrated libel. Libel refers to false written statements damaging to a person's reputation; the UAP's verbal threat does not fall under this definition, as it was spoken, not written.
The nurse in charge of the labor and delivery department is making the client assignments for the day. Which client should the most experienced nurse receive?
Rationale:
A 40-week pregnant client attached to the fetal monitor having late decelerations should be assigned to the most experienced nurse. This situation indicates potential fetal distress, requiring advanced skills for monitoring and intervention.
B: A 39-week pregnant client in labor with contractions 3 minutes apart presents a typical labor scenario, manageable by nurses with standard experience. Urgency is lower than in option A.
C: A 33-week pregnant client with triplets on bed rest is stable, but the complexity of multiple pregnancies requires attention. However, the immediate risk is not as critical as in option A.
D: A 26-week pregnant client having Braxton Hicks contractions indicates false labor symptoms. This situation typically does not necessitate the expertise of the most experienced nurse, as it is less critical.
The nurse has care of the following client situations under their care. The nurse should first assess which client?
Rationale:
A: A client with chronic pulmonary obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reports a productive positive cough. This client demonstrates effective breathing techniques and stable symptoms, indicating lower priority for immediate assessment compared to others.
B: A client who had a laparoscopic appendectomy cholecystectomy three days ago and has right shoulder pain and abdominal cramps. While post-operative pain is concerning, it’s less urgent than potential bleeding.
C: A client with ulcerative colitis, who has had three bloody stools in the past two days and reports abdominal cramping. Although alarming, the situation is not as critical as active hemorrhage.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
Rationale:
Witnessing informed consent for a client needing an emergency laparotomy is a priority task for the nurse. This action is crucial to ensure the client understands the procedure and risks, fulfilling legal and ethical responsibilities before surgery.
A: teaching a client scheduled for discharge how to ambulate with crutches. While important, discharge education does not take precedence over urgent surgical consent requirements in this scenario.
C: irrigating a client's ostomy who reports abdominal cramping. Although this task addresses a client's immediate discomfort, it is not as critical as securing consent for an emergency procedure.
D: calculating the intake and output of a client with diabetes insipidus (DI). Monitoring fluid balance is essential but does not require immediate action like obtaining informed consent for surgery.
A charge nurse is preparing client assignments for the shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?
Rationale:
C: A client 24 hours post-abdominal surgery requiring daily wound care. This assignment is appropriate because LPNs/VNs are trained to perform basic post-operative care, including wound management and monitoring for complications.
A: A client with a chest tube requiring frequent oral suctioning. This task necessitates advanced skills and critical assessment abilities typically outside the LPN/VN scope of practice.
B: A client receiving continuous IV heparin for a pulmonary embolism (PE). Managing heparin therapy involves complex assessments and potential adjustments that are generally beyond the LPN/VN's responsibilities.
D: A client with new-onset seizures awaiting diagnostic tests. This situation requires immediate nursing assessments and interventions that demand the expertise of a registered nurse rather than an LPN/VN.
The nurse is caring for assigned clients. The nurse should prioritize seeing the client who
Rationale:
A: has a chest tube attached to a closed-chest drainage system to treat a pneumothorax and reports increased dyspnea and dizziness. This client exhibits concerning symptoms that suggest a potential life-threatening situation, requiring immediate assessment and intervention to ensure airway patency and effective ventilation, making them the highest priority for the nurse's attention.
B: is being treated for acute pancreatitis and reports nausea and pain rated 6 on a scale of 0 (no pain) to 10 (severe pain). While the client is experiencing discomfort, their vital signs and overall condition appear stable, allowing for less immediate intervention compared to clients facing respiratory distress or acute complications.
C: is being treated for pheochromocytoma and reports a headache, and most recent blood pressure is 149/84 mm Hg. Although hypertension is a concern, the client’s symptoms are not as acute or critical as those presented by the client with dyspnea and dizziness, indicating less urgency.
D: has pneumonia with atelectasis and has had decreased breath sounds in the affected lobe. While this condition requires monitoring, the immediate risk to airway and ventilation posed by the client with a chest tube takes precedence, highlighting a greater urgency in their care.
The registered nurse (RN) delegates client assignments to a licensed practical/vocational (LPN/VN) and unlicensed assistive personnel (UAP). Which client assignment should be delegated to a UAP? A client
Rationale:
B: A client admitted with atrial fibrillation that requires vital signs every three hours. This task is appropriate for a UAP, as it involves routine monitoring that does not require specialized nursing judgment or intervention.
A: A client newly diagnosed with hypothyroidism and requires teaching. Teaching clients necessitates the expertise of an RN to ensure comprehensive understanding and address potential complications effectively.
C: A client immediately postoperative following total hip arthroplasty that is reporting pain. This situation demands assessment and pain management strategies that only a licensed nurse can provide, ensuring patient safety.
D: A client ready for discharge and requires reinforcement of discharge instruction. Reinforcing discharge instructions involves critical evaluation and clarification of information that should be conducted by an RN to ensure proper understanding.
The nurse offers to stay late to assist the next shift because they are short-staffed. Which ethical principle is the nurse demonstrating?
Rationale:
The nurse is demonstrating beneficence.
This principle emphasizes actions that promote the well-being of patients and others. By offering to stay late, the nurse prioritizes patient care and safety, ensuring adequate support during a critical time.
A: Non-maleficence This principle focuses on avoiding harm, which does not capture the nurse's proactive choice to enhance patient safety through additional assistance.
B: Paternalism This involves making decisions for others under the belief it is in their best interest, which does not reflect the nurse's voluntary offer to help.
D: Veracity This principle pertains to truthfulness and honesty, which is unrelated to the nurse's action of staying late to provide support to the next shift.
The nurse has received the following prescriptions for newly admitted clients. Which medication should the nurse administer first?
Rationale:
C: Intravenous (IV) fluids for sepsis. Administering IV fluids for sepsis is critical, as it addresses immediate fluid resuscitation needs, stabilizes hemodynamics, and helps combat potential septic shock effectively, ensuring patient safety.
A: Subcutaneous (SubQ) epoetin for anemia. While important for treating anemia, epoetin does not address acute conditions and requires time to take effect, making it a lower priority in emergencies.
B: oxycodone by mouth (PO) for pain control. Oral administration of oxycodone is not suitable for immediate pain relief in a critical situation, as it takes longer to achieve therapeutic levels.
D: Intramuscular (IM) hydroxyzine for anxiety. Although hydroxyzine can help manage anxiety, it is less urgent than IV fluids for sepsis and does not address life-threatening conditions.
The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply.
Rationale:
A, F
To correct the error, the nurse should draw a line through the erroneous documentation and write their initials, date, and time above it with the word 'error.' This maintains the integrity of the record while ensuring clarity about the mistake.
B: using correction tape and write over the error. This method obscures the original entry, compromising the transparency required in medical documentation.
C: writing over the error in darker ink. Altering the documentation this way can lead to confusion and does not provide a clear record of the original mistake.
D: completely black out the error with a black marker. This approach obscures the information entirely, making it impossible to reference the original documentation or track changes.
E: discarding the documentation in the trash and starting over. This action eliminates the record of the original entry, violating standards of accountability and continuity in patient care.
A patient has completed a living will stating that he does not want intubation, mechanical ventilation, or artificial nutrition/hydration should he become unable to communicate his preferences related to medical care. However, the patient's adult children have expressed their opposition to the patient's wishes. Which are appropriate nursing actions? Select all that apply.
Rationale:
Notify the patient's physician, the nursing supervisor, and the risk manager. Encouraging family discussions and involving the ethics committee are essential to navigate conflicts between the patient’s wishes and family opposition, ensuring ethical care is prioritized and the patient’s autonomy respected.
B: Explain to the patient's family that the living will cannot be changed at this point. This action dismisses family concerns and does not facilitate communication or resolution of the conflict surrounding the patient's wishes.
E: Advise the patient to just go along with the wishes of his adult children. This approach undermines the patient's autonomy and disregards the validity of their living will, which clearly outlines their preferences.
The nurse has been made aware of the following client situations. The nurse should first assess the client that
Rationale:
The client that is three hours post-operative from the placement of an ileostomy and has an edematous reddened stoma should be assessed first.
This option indicates a recent surgical procedure, which presents a higher risk for complications such as stoma necrosis or infection. The condition of the stoma requires immediate evaluation to ensure proper healing and to prevent serious complications, making it a priority for assessment.
A: is in a private room, and their stage III pressure ulcer tests positive for Pseudomonas aeruginosa. Although this situation is serious, it involves established care protocols rather than immediate intervention, allowing for delayed assessment.
C: has type 2 diabetes mellitus and a morning blood glucose of 76 mg/dL (4.2 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L], and refuses breakfast. The blood glucose level is within a safe range, and refusal of breakfast does not present an acute concern requiring urgent assessment.
D: is awaiting an appendectomy and reports increased pain with coughing and is relieved by bending the right hip. While this client shows discomfort, the symptoms may be typical pre-operative pain and do not indicate an acute need for immediate evaluation.
The nurse has received a telephone prescription from the primary healthcare provider (PHCP) for citalopram 10 mg PO daily. Which action is the nurse's priority while taking the telephone order?
Rationale:
B: Reading back the prescription to the PHCP ensures accuracy and confirms that the nurse has correctly understood the order. This step is crucial to prevent medication errors and ensure patient safety.
A: Verifying that the medication is in stock does not address the immediate need for accurate communication of the prescription details. Prioritizing accuracy of the order takes precedence.
C: Informing the client of the new prescription is not the nurse's immediate responsibility; ensuring the prescription is accurate and confirmed must come first to avoid miscommunication.
D: Transmitting the prescription to the pharmacy is premature without first confirming the accuracy of the prescription with the PHCP, which is essential to prevent dispensing errors.
The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed
Rationale:
A: intravenous hydromorphone for chronic back pain and is drowsy. Drowsiness can be a common side effect of hydromorphone, and monitoring may be necessary but does not indicate an urgent issue.
B: intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw. Involuntary movements indicate a potential acute reaction to metoclopramide, necessitating immediate assessment for possible serious side effects like tardive dyskinesia.
C: intravenous dexamethasone for chronic bronchitis reporting perineal itching. Perineal itching may signal an allergic reaction but is not as critical as other symptoms that require urgent intervention.
D: nitroglycerin infusion for chest pain and reports a headache. Headaches are a common side effect of nitroglycerin and generally manageable, not indicating an immediate need for further assessment.
The nurse is planning care for a client being admitted with cardiac dysrhythmias. When planning care for this client, the nurse should prioritize
Rationale:
Establishing continuous electrocardiogram (ECG) monitoring. This priority allows for real-time assessment of the client's cardiac rhythm, enabling prompt identification of any dysrhythmias and timely intervention, which is crucial for patient safety.
A: Auscultating heart tones. While important for assessing cardiac function, it does not provide continuous monitoring or immediate feedback necessary for managing cardiac dysrhythmias effectively.
C: Obtaining vital signs. Although vital signs are essential, they offer only periodic information and do not address the continuous monitoring required for immediate intervention in dysrhythmias.
D: Establishing a secondary peripheral vascular access device. This action may be useful for medication administration but does not directly pertain to monitoring or managing the patient's cardiac condition.
The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
Rationale:
D: Suctions a tracheostomy for 10 seconds as they remove the catheter. Suctioning a tracheostomy for 10 seconds is excessive and can lead to hypoxia; appropriate practice involves limiting suctioning time to ensure patient safety and comfort.
A: Humidifies nasal cannula oxygen for a client with sarcoidosis. Humidification of oxygen is beneficial for clients with respiratory conditions, aiding in moisture retention and preventing airway irritation.
B: Secures a suprapubic catheter tubing to a client’s inner thigh. Securing catheter tubing to the inner thigh is standard practice, as it helps prevent dislodgment and maintain patient comfort without risking injury.
C: Places a client with varicella-zoster in airborne and contact isolation. Varicella-zoster requires both airborne and contact precautions, meeting the necessary infection control standards to protect others from potential exposure.
The emergency department (ED) nurse performs triage. Which client should the nurse prioritize care for? A client with
Rationale:
A client with hemophilia reporting knee and ankle stiffness with dizziness should be prioritized.
This client exhibits symptoms that suggest a potential bleeding episode, which could lead to serious complications. The combination of joint stiffness and dizziness indicates a possible significant drop in hemoglobin due to internal bleeding, necessitating immediate medical intervention to prevent further deterioration.
B: chronic obstructive pulmonary disease (COPD) reporting a productive cough. While concerning, this condition typically does not present the same immediate life-threatening risks as the symptoms of hemophilia in this context.
C: chronic pericarditis reporting intermittent chest pain during inspiration. Although chest pain is serious, intermittent nature and the lack of acute distress signal it may not require emergency prioritization compared to potential bleeding issues.
D: pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses. These symptoms suggest sinusitis or dental issues, which are less urgent than potential hemorrhagic complications faced by the hemophilia patient.
The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor. Select all that apply.
Rationale:
A, B, E. These situations necessitate an incident report due to potential risks and safety concerns. Refusing PPE poses a health risk, adjusting an infusion pump could lead to medication errors, and a fall indicates a safety incident requiring documentation.
C: requesting that their family member get pain medication. This action is a standard request and typically does not require an incident report unless complications arise.
D: assisting their family member with brushing their teeth. This is a routine caregiving task and does not constitute an incident that needs reporting in the context provided.
The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
Rationale:
B: A 26-year-old female requiring a one-person assist in ambulating to the restroom. This task is appropriate for unlicensed assistive personnel as it involves basic mobility assistance and does not require clinical judgment or specialized knowledge.
A: A 65-year-old male requiring sterile dressing changes. This task necessitates sterile technique and clinical expertise, which unlicensed assistive personnel are not trained to perform safely and effectively.
C: An 80-year-old male who is receiving enteral feedings continuously through an NG tube. Continuous enteral feedings require monitoring and management skills that unlicensed assistive personnel do not possess, making this assignment inappropriate.
D: A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter. This procedure requires knowledge of aseptic techniques and patient assessment, which is beyond the scope of unlicensed assistive personnel.
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Establish a large bore peripheral vascular access device to unburned skin.
B
Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
C
Administer tetanus prophylaxis as prescribed.
D
Administer supplemental oxygen if indicated and cover burns with sterile gauze.
E
Assess the client's airway, breathing, and circulation and obtain vital signs.
F
Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Rationale:
E: Assess the client's airway, breathing, and circulation and obtain vital signs. Initial assessment is crucial to identify life-threatening issues, ensuring that the client’s respiratory and circulatory status is stable before further interventions.
D: Administer supplemental oxygen if indicated and cover burns with sterile gauze. While essential for burn care, this action follows initial assessment to ensure the client’s airway and circulation are prioritized first.
A: Establish a large bore peripheral vascular access device to unburned skin. Although establishing IV access is necessary for fluid resuscitation, it is secondary to assessing life-threatening conditions first.
F: Administer prescribed isotonic fluids intravenously to maintain fluid balance. Fluid resuscitation is vital, yet it can only commence after securing the airway and ensuring stable vital signs.
B: Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr. This step is important for monitoring renal function but should occur after addressing immediate airway and circulation concerns.
C: Administer tetanus prophylaxis as prescribed. While tetanus prophylaxis is necessary, it is a lower priority compared to immediate life-support measures and fluid resuscitation in burn management.
The nurse is caring for assigned clients. Which of the following activities should the nurse perform first?
Rationale:
C: Administer diazepam for a client with delirium tremens (DTs). This activity should be prioritized due to the acute risk of severe complications associated with DTs, including seizures and potential life-threatening symptoms that necessitate immediate intervention.
A: Administer acetaminophen to a client with a temperature of 101.1°F (38.4°C). While fever management is important, it does not pose an immediate life-threatening risk compared to the urgency of DTs.
B: Complete pin care for a client with a halo fixation device. Although essential for preventing infection, this task does not require immediate attention and can be delayed without significant risk to the patient.
D: Insert an indwelling urinary catheter for a client with retention. This procedure is necessary but can safely wait, as it does not address any acute or critical health issues like those presented in DTs.
The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply.
Rationale:
Battery is an intentional touching of another's body without the other's consent.
The context confirms that battery involves non-consensual physical contact, highlighting the importance of consent in nursing practice. Understanding this concept is crucial for maintaining patient autonomy and legal standards in healthcare settings.
D: Defamation is presenting false credentials for employment. This statement misconstrues defamation, which involves damaging someone's reputation through false statements, not credential misrepresentation.
E: Occurrence reports reduce the liability for a negligent tort. While occurrence reports document incidents, they do not inherently reduce liability; they serve more as tools for risk management and improvement.
The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of
Rationale:
B: veracity. This ethical principle emphasizes the importance of truthfulness in communication with clients. By maintaining honesty, the nurse fosters trust and promotes informed decision-making, essential for effective patient care and support.
A: beneficence. This principle focuses on promoting good and acting in the best interest of patients, but does not specifically address the necessity of honesty in communication.
C: nonmaleficence. This principle pertains to avoiding harm to patients, but it does not directly relate to the obligation of transparency and truthful communication in nursing practice.
D: fidelity. While this principle emphasizes loyalty and keeping promises, it does not specifically highlight the critical aspect of honesty and openness when delivering potentially distressing information.
The charge nurse is reviewing assignments on the nursing unit for the upcoming shift. Which room assignment should be changed based on the nurse assigned? See the exhibit. Select all that apply.
Rationale:
B: Room 2, E: Room 5, F: Room 6 should be changed because the assigned nurses lack the necessary experience or training to handle the specific needs of the patients in these rooms. Proper alignment of skill sets with patient requirements is crucial for quality care.
A: Room 1. The nurse assigned to this room possesses the appropriate skills and experience to meet the patient's needs effectively.
C: Room 3. The nurse assigned demonstrates competence and familiarity with the patient’s condition, ensuring safe and effective care delivery.
D: Room 4. The staff member assigned here has the relevant training and experience, making them suitable for the patient's requirements.
G: Room 7. The nurse in charge of this room shows adequate capability to address the patient's health concerns, thus maintaining quality care standards.
The charge nurse is orientating a newly hired nurse to the charge nurse role. Which observation by the charge nurse requires follow-up? The newly hired nurse Select all that apply.
Rationale:
The newly hired nurse requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology. This action requires follow-up as it poses a risk by delegating critical responsibilities to unlicensed staff.
A: requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology. This delegation overlooks the need for skilled assessment and intervention during a potentially critical situation.
B: asks the licensed practical/vocational nurse (LPN/VN) to witness informed consent for a client scheduled for surgery. Witnessing informed consent requires a registered nurse or physician to ensure legal and ethical standards are met.
C: instructs the licensed practical/vocational nurse (LPN/VN) to review orders just written by the physician. Delegating order review aligns with LPN/VN responsibilities, as they are trained to interpret and follow physician orders.
D: asks the unlicensed assistive personnel (UAP) to transport blood specimens to the lab. Transporting specimens is permissible for UAP, as it involves no clinical judgment or assessment critical for patient safety.
E: assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN). This assignment may be appropriate depending on the complexity of the client's condition and LPN/VN's competencies.
The nurse is caring for a group of clients in the emergency department. Which client situation requires immediate follow-up? A client
Rationale:
A: transdermal nitroglycerin applied for angina and newly nits reports a headache. Headaches are a common side effect of nitroglycerin and typically do not require urgent intervention unless accompanied by severe symptoms.
B: receiving intravenous fluids for diabetic ketoacidosis and has an outstanding order for a regular insulin infusion. The outstanding insulin order is critical, as timely insulin administration is essential for managing diabetic ketoacidosis effectively, preventing complications.
C: receiving a continuous infusion of esmolol for an abdominal aortic aneurysm and reports flank pain. Flank pain could indicate complications, but it is not as immediately life-threatening as the insulin need in DKA.
D: who just received discharge orders and needs teaching on how to care for their fractured radius. While teaching is important, it is not an immediate concern compared to urgent medical needs in other situations.
A nurse observes a colleague failing to perform hand hygiene before entering multiple client rooms and administering medications. What is the most appropriate action by the nurse?
Rationale:
C: Immediately report the behavior to the nurse manager for follow-up. Reporting the situation ensures that a serious breach of infection control protocols is addressed promptly, safeguarding both patient safety and adherence to professional standards.
A: Confront the colleague immediately in a client's room to stop the behavior. This approach risks escalating tension in front of patients and may not effectively resolve the underlying issue.
B: Document the incident in the nurse's notes while monitoring for further issues. While documentation is important, mere observation without immediate action fails to address the urgent need for compliance with hygiene protocols.
D: Assume the colleague is having a busy shift, and address it at a later time. Delaying action can compromise patient safety, as hand hygiene is critical in preventing infections and maintaining health standards.
The nurse is reviewing leadership and management concepts with a student nurse. Which of the following statements by the student nurse would require follow-up?
Rationale:
A: The Laissez-faire leadership style is a passive leadership approach. This statement accurately describes the Laissez-faire style, highlighting its non-intrusive nature and allowing team members to operate with minimal guidance, which is a correct understanding.
C: The rights of delegation include task, circumstance, person, direction, supervision. This accurately enumerates the essential elements of delegation rights in nursing, demonstrating a sound grasp of delegation principles.
D: The nurse practice act defines roles and responsibilities of nursing professionals. This correctly identifies the nurse practice act’s function in establishing professional standards and scope, indicating a clear comprehension of regulatory frameworks in nursing.
A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.
Rationale:
C: Determine the patient's knowledge base related to infant feeding options. Understanding the patient's knowledge allows the nurse to provide tailored information, address any misconceptions, and support the patient's informed decision-making process regarding formula feeding.
A: Remind the patient of why breast feeding is the best method of infant feeding. This approach dismisses the patient's choice and may create feelings of guilt rather than fostering an open dialogue.
B: Request a referral to the lactation consultant. While this can be beneficial, it does not directly advocate for the patient's autonomy in choosing formula feeding, potentially undermining her decision.
D: Accept the patient's decision without further discussion. This approach neglects the opportunity to engage with the patient about her knowledge and beliefs, which is essential for informed decision-making.
The nurse is caring for assigned clients. The nurse should initially follow up on the client who
Rationale:
A: has a basilar skull fracture and has bruises under their eyes. While this condition is concerning, the presence of bruising alone does not necessitate immediate intervention compared to changes in neurological status.
C: has amyotrophic lateral sclerosis (ALS) and is requesting to have resuscitation efforts withheld. This request indicates a stable decision-making process, not an urgent clinical condition requiring immediate follow-up from the nurse.
D: has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness. Muscle weakness is a common symptom of GBS; however, it does not reflect an acute change in clinical status that demands urgent attention.
The nurse is caring for assigned clients. The nurse should initially assess the client who
Rationale:
A: The client recovering from a femoral angioplasty reporting foot numbness should be prioritized for assessment. This symptom could indicate compromised blood circulation or a serious complication, necessitating immediate evaluation and intervention.
B: The client with diabetes mellitus refusing glargine insulin may face elevated blood sugar levels, but their situation is not as immediately critical as potential vascular issues affecting the client in option A.
C: The client who received alteplase for a stroke and has a Glasgow Coma Scale of 14 is stable and responsive. While monitoring is essential, they do not require urgent assessment compared to option A.
D: The client with a T6 spinal cord injury who hasn't had a bowel movement since yesterday may require attention, yet this condition lacks the immediate urgency of potential vascular complications seen in option A.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP?
Rationale:
A: Obtain a tympanic temperature for a client who received naproxen one hour ago. This task is appropriate for a UAP as it involves a simple, non-invasive procedure that does not require nursing judgment or assessment skills, allowing nurses to focus on more complex care needs.
B: Record and empty a closed suction drain for a client recovering from a mastectomy. This task requires specialized knowledge and assessment skills to ensure proper care and management of the surgical site and drain.
C: Assist a client in picking out low-sodium foods on their lunch menu. This task involves dietary knowledge and guidance, which typically falls within the nursing scope of practice rather than UAP responsibilities.
D: Transport a client receiving an infusion of dopamine to the intensive care unit. This task requires monitoring and assessment of the patient’s condition during transport, which is beyond the UAP's scope of practice.