1. 1. Checking the client’s arm band is done prior to actually administering the medica- tions, but it is not the first action for the nurse to take.
2. The nurse should have assessed the client’s IV site on first rounds. At this time, all medications to be administered are oral. 3. This is part of the two-identifier system of
medication administration implemented to prevent medication errors, but it is not the first action for the nurse to take.
4. The nurse should assess the client’s last potassium (K⫹) level because hy-
pokalemia (abnormally low K⫹level) is
the most common cause of dysrhythmias in clients receiving digoxin secondary to clients concurrently taking
diuretics. Furosemide (Lasix) is a loop diuretic. The nurse should check for digoxin and K⫹levels and apical pulse
(AP) prior to administering digoxin. 2. 1. Elderly clients diagnosed with pneumo-
nia may not present with the “normal” symptoms, such as fever. The client’s becoming restless may indicate a decrease in oxygen to the brain. This client should be seen first.
2. Two-plus edema is expected in a client diag- nosed with cellulitis.
3. One of the typical main symptoms of diverti- culitis is crampy left lower quadrant pain; therefore, this client does not require inter- vention.
4. Sinus drainage is to be expected in a client diagnosed with a sinus infection.
3. 1. The telemetry strip indicates artifact, so there is no need for the UAP or any staff member to call a Code Blue, which is used when someone has arrested.
2. The UAP should be instructed to check the telemetry lead placement; this read- ing is artifact because the client is talking to the unit secretary over the intercom system.
3. The UAP can take care of this problem; there is no need for the primary nurse to check the client.
4. The strip indicates artifact, but there is no indication that the client should be removed from telemetry.
4. 1. Altered nutrition is a concern, but a client can live for several weeks on minimal intake. 2. Self-care deficit is a psychosocial problem;
physiologic problems have priority.
3. Impaired body image is a psychosocial prob- lem; physiologic problems have priority.
4. Fluid and electrolyte imbalance can cause cardiac dysrhythmias. This is the priority problem.
5. 1. This is a routine medication that has a time frame of 30 minutes before and after the scheduled time to be administered. This medication does not need to be the first medication administered.
2. Aricept can be administered within the 30-minute time frame. This medication does not need to be the first medication administered.
3. A mucosal barrier agent must be admin- istered before the client eats in order for the medication to coat the gastric mucosa. This medication should be administered first.
4. Lovenox can be administered within the 30-minute time frame. This medication does not need to be the first medication administered.
6. 1. This should be done if the murmur is a new finding; however, the nurse should investi- gate the finding further before notifying the HCP.
2. This should be done, but assessing the client’s situation is the nurse’s priority.
3. Although the client was not admitted for a cardiac problem, she may have had a murmur for a while, and the previous nurse did not pick it up or did not men- tion it in the report because it was a long-standing physiologic finding in this client. The nurse should research the chart for a current history and physical to determine whether the HCP is aware of the condition.
4. The nurse should not ask the client because this could scare or alarm the client needlessly.
7. 1. This client has been on a medication to control the angina for 2 days and could be discharged.
2. This client is currently completing the amount of care that would be provided in the hospital setting. The client can be taught to continue the Coumadin at home and return to the HCP’s office for blood work, or a home health nurse can be assigned to go to the client’s home and draw blood for the lab work.
3. Because resistant infections are very difficult to treat, this client should remain in the hospital for the required IVPB medication.
4. These blood gases are expected for a client diagnosed with COPD. This client could go home with oxygen and home health follow-up care.
8. 1. This client should be referred to an inpatient rehabilitation facility for in- tensive therapy before deciding on long-term placement (home with home health care or a long-term care facility). The initial rehabilitation a client receives can set the tone for all further recuperation. This is the appropriate referral at this time.
2. A home health-care agency may be needed when the client returns home, but the most appropriate referral is to a rehabilita- tion center where intensive therapy can take place.
3. A long-term care facility may be needed at some point, but the client should be given the opportunity of regaining as much lost ability as possible at this time.
4. The outpatient center would be utilized when the client is ready for discharge from the inpatient center.
9. 1. The nurse should be the first one to feed the client, in order for the nurse to evalu- ate the client’s ability to swallow and not aspirate.
2. The LPN could administer routine parenteral medications. This is the best task to assign to the LPN.
3. This involves assessing the client; there- fore, the nurse should not delegate this assignment to the LPN.
4. Teaching is the responsibility of the RN.
10. 1 and 2 are correct.
1. Checking the client’s skin involves assessment; therefore, the nurse cannot delegate this assignment to the UAP. 2. The nurse cannot delegate medication
administration to a UAP.
3. The UAP can perform routine hygiene care. The nurse must then make the time to assess the client’s skin.
4. The UAP can ambulate a client to the bathroom.
5. The UAP can take routine vital signs.
11. 1. The client’s lab work does not indicate an increased risk for infection. The client does not need to be placed in reverse isolation.
2. The lab work is within normal limits. The nurse does not need to notify the HCP. 3. The client is not at an increased risk for
infection; therefore, the client may have flowers in the room.
4. This client’s lab work is within normal limits. The nurse should continue to monitor the client.
12. 1. The nurse may wish to consult the hospital’s attorneys or retain an attorney of his or her own, but this is not the first action for the nurse.
2. The nurse should be familiar with the chart and the situation so that details can be remembered. This should be the nurse’s first action.
3. It is too late to purchase liability insurance to cover the current situation. The nurse may wish to purchase insurance for any future litigation.
4. The nurse should refrain from discussing the case with anyone who could be called as a witness or be named in the suit.
13. 1. One of the many jobs of a manager is to see that performance evaluations are completed on the staff.
2. The manager should receive input from many sources to make decisions. Some decisions are made for the manager by administration based on costs or any num- ber of other reasons.
3. The nurses retain responsibility for their own actions because they practice under the state’s nursing practice act. The manager retains responsibility for the functioning of the unit.
4. The nurse manager attends many meet- ings pertaining to nursing but attends medical committee meetings only when a nursing issue is being discussed.
14. 1. Usually, the charge nurse should attempt to settle a conflict at the lowest level possible, in this case, confronting the nurse. However, the charge nurse does not have the authority to require a drug screen, which is the intervention needed in this situation. The nurse should notify the unit manager.
2. The charge nurse does not have the authority to force the nurse to submit to a drug screening, which is what this behavior suggests. Therefore, the charge nurse should not confront the staff nurse. The nurse should notify the supervisor.
3. Nurses have the right to take breaks with or without their peers. The charge nurse cannot enforce this option.
4. An occurrence report is not used for this type of situation. This is a management or a peer review issue. The nurse can go
through the manager or a peer review com- mittee.
15. 1. The nurse should stop the behavior occurring in a public place. The charge nurse can discuss the issue with the UAPs and determine whether the manager should be notified.
2. The first action is to stop the argu- ment from occurring in a public place. The charge nurse should not discuss the UAPs’ behavior in public.
3. The second action is to have the UAPs go to a private area before resuming the con- versation.
4. The charge nurse may need to mediate the disagreement; this would be the third step.
16. 1. The graduate nurse should handle the sit- uation directly with the UAP first before notifying the charge nurse.
2. This may need to be completed, but not prior to directly discussing the behavior with the UAP.
3. The graduate nurse must address the insubordination with the UAP, not just complete the tasks that are the responsi- bility of the UAP.
4. The graduate nurse must discuss the insubordination directly with the UAP first. The nurse must give objective data as to when and where the UAP did not follow through with the com- pletion of assigned tasks.
17. 1. Telling jokes with sexual innuendos creates a “hostile work environment” and should be addressed with the HCP. This is a courtesy to the HCP to allow him to correct the behavior without being embarrassed.
2. If the behavior is not corrected, then the nurse should report the HCP to the man- ager or chief nursing officer (CNO). The manager or CNO may find it necessary to report the behavior to the medical staff committee or president.
3. The charge nurse should first report the behavior to the manager and the, if the problem is not resolved, to the CNO, or, in other words, follow the chain of command. 4. Some facilities have a code for staff to use
when an HCP is acting out, but it is rarely, if ever, used.
18. 1. The new graduate cannot take a break whenever he or she becomes overwhelmed because the work may never get done. The new graduate should schedule breaks throughout the shift, not when he or she wants to take them.
2. The preceptor should recommend that the new graduate use some tool to organize the work so that important tasks, such as medication administration and taking vital signs, are not missed.
3. Encouraging the new graduate to calm himself or herself down (five deep breaths) before beginning work is good, but it will not help the new graduate with time management.
4. The new graduate must find the best way to organize himself or herself. Doing the organizing for the new graduate will not help him or her.
19. 1. Synthroid is a medication used to treat hypothyroidism; therefore, the nurse would not question administering this medication.
2. Inderal is administered to decrease the heart rate in clients diagnosed with hyper- thyroidism; therefore, the nurse would not question administering this medication.
3. Procardia decreases blood pressure; therefore, the nurse should question administering this medication to a client with hypotension.
4. Vasotec, an ACE inhibitor, is administered to clients with diabetes to help prevent diabetic nephropathy. The nurse would not question administering this medication.
20. 1. This client is exhibiting signs and symp- toms of a potentially fatal complication of DVT—pulmonary embolism. The nurse should assess this client first.
2. Refusing to eat hospital food should be discussed with the client, but the nurse could ask the unit secretary to have the dietitian see the client.
3. Clients diagnosed with pancreatitis have nasogastric tubes to rest the bowel. How- ever, these tubes are typically uncomfort- able. Regardless, the nurse should see this client after the client diagnosed with DVT has been assessed and appropriate inter- ventions initiated. The nurse should dis- cuss the importance of maintaining the tube with the client.
4. This is an expected symptom of osteoarthritis. This client does not need to be assessed first.