A charge nurse in the emergency department is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is appropriate for the float nurse?
Administer IV nitroglycerin to a client who is experiencing chest pain.
Complete a SAD PERSONS assessment scale for a client who has attempted suicide.
Set up a trauma room for an incoming client who was in a motor-vehicle crash.
Perform a urinary catheterization for a client who has experienced a cerebrovascular accident.
The Correct Answer is D
Choice A reason: Administering IV nitroglycerin to a client who is experiencing chest pain is not an appropriate assignment for the float nurse, as it requires advanced cardiac knowledge and skills that the nurse may not have. The charge nurse should assign this task to a nurse who is experienced in the emergency department.
Choice B reason: Completing a SAD PERSONS assessment scale for a client who has attempted suicide is not an appropriate assignment for the float nurse, as it requires mental health expertise and training that the nurse may not have. The charge nurse should assign this task to a nurse who is qualified in psychiatric nursing.
Choice C reason: Setting up a trauma room for an incoming client who was in a motor-vehicle crash is not an appropriate assignment for the float nurse, as it requires emergency preparedness and competence that the nurse may not have. The charge nurse should assign this task to a nurse who is familiar with the trauma protocols and equipment.
Choice D reason: Performing a urinary catheterization for a client who has experienced a cerebrovascular accident is an appropriate assignment for the float nurse, as it is a basic nursing skill that the nurse should have learned and practiced in the medical-surgical unit. The charge nurse should assign this task to the float nurse as long as the nurse is comfortable and confident with the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as hospice care provides comprehensive and compassionate care for clients who have a life expectancy of six months or less. Hospice care involves a team of health care professionals, such as physicians, nurses, social workers, chaplains, and volunteers, who address the physical, emotional, social, and spiritual needs of the client and their family.
Choice B reason: This statement is incorrect, as hospice care is not intended for clients at various stages of chronic illness. Hospice care is only for clients who are terminally ill and have decided to forego curative or aggressive treatments.
Choice C reason: This statement is incorrect, as hospice care does not prolong the life expectancy of clients who are terminally ill. Hospice care focuses on improving the quality of life and comfort of the client, not on extending their life span.
Choice D reason: This statement is incorrect, as hospital access is still available for clients who are in hospice care. Hospice care can be provided in various settings, such as the client's home, a hospice facility, a nursing home, or a hospital. Clients who are in hospice care can still be admitted to the hospital if they need acute care or symptom management.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the most urgent and potentially life-threatening problem. Urinary retention after spinal surgery can lead to bladder distension, infection, renal damage, or autonomic dysreflexia (a dangerous rise in blood pressure and heart rate). The nurse should assess the client's bladder, catheterize the client if indicated, and notify the surgeon.
Choice B reason: This is not the correct choice because this client has a serious but not urgent problem. Pancreatic cancer is a malignant tumor that can affect the function of the pancreas and other organs. IV chemotherapy is a treatment that uses drugs to kill cancer cells. The nurse should provide emotional support, education, and symptom management to this client, but they are not the highest priority.
Choice C reason: This is not the correct choice because this client has a chronic but not acute problem. Peripheral vascular disease is a condition that affects the blood vessels outside the heart and brain, causing reduced blood flow to the limbs. An absent pedal pulse indicates poor circulation in the foot, which can lead to pain, numbness, or tissue damage. The nurse should monitor the client's pulses, skin temperature, and color, and teach the client how to prevent complications, but they are not the highest priority.
Choice D reason: This is not the correct choice because this client has a stable but not critical problem. MRSA is a type of bacteria that is resistant to many antibiotics and can cause skin or systemic infections. An axillary temperature of 38°C (101°F) indicates a mild fever, which is a common sign of infection. The nurse should administer antibiotics as prescribed, observe the client for signs of sepsis, and follow infection control precautions, but they are not the highest priority.
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