A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?
The emergency department nurse is waiting to give report on a new admission.
A nurse on the previous shift wrote an incident report about a medication error.
Two staff members have called to say they will be absent.
Transport assistance is unavailable to take a client to occupational therapy.
The Correct Answer is A
Choice A reason: The charge nurse should address the situation of the emergency department nurse waiting to give report on a new admission first. This is the most urgent and time-sensitive issue that affects the client's safety and continuity of care. The charge nurse should assign a staff nurse to receive the report and prepare for the admission.
Choice B reason: The charge nurse should address the situation of a nurse on the previous shift writing an incident report about a medication error second. This is an important and serious issue that requires follow-up and corrective actions. The charge nurse should review the incident report, talk to the nurse involved, and implement measures to prevent future errors.
Choice C reason: The charge nurse should address the situation of two staff members calling to say they will be absent third. This is a significant and challenging issue that affects the staffing and workload of the unit. The charge nurse should contact the staffing office, request replacements, and adjust the assignments accordingly.
Choice D reason: The charge nurse should address the situation of transport assistance being unavailable to take a client to occupational therapy last. This is a minor and temporary issue that does not compromise the client's health or well-being. The charge nurse should contact the transport department, reschedule the therapy session, and inform the client and the therapist.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The state nurse practice act is an appropriate resource for the nurse to consult in planning for this policy. The state nurse practice act defines the scope of practice and the legal authority for nurses in each state. The nurse should ensure that the policy is consistent with the state regulations and does not exceed the nurse's level of competence and education.
Choice B reason: The ANA Standards of Practice are not the most appropriate resource for the nurse to consult in planning for this policy. The ANA Standards of Practice describe the expectations and responsibilities for the professional nursing practice, such as assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The standards are general and broad, and do not provide specific guidance on the procedure of removing chest tubes.
Choice C reason: The ANA Code of Ethics is not the most appropriate resource for the nurse to consult in planning for this policy. The ANA Code of Ethics outlines the ethical principles and values that guide the nursing practice, such as respect, autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity. The code does not address the technical or legal aspects of removing chest tubes.
Choice D reason: The Institute of Medicine is not the most appropriate resource for the nurse to consult in planning for this policy. The Institute of Medicine is an independent, nonprofit organization that provides evidence-based recommendations and research on health care issues, such as quality, safety, and innovation. The institute does not regulate or define the nursing practice or scope.
Correct Answer is A
Explanation
Choice A reason: Collecting the client's urine output every 24 hours is a task that the nurse can delegate to an AP. This task is within the AP's scope of practice and does not require clinical judgment or assessment. The nurse should provide clear instructions and expectations to the AP, and monitor and evaluate the client's fluid status and renal function.
Choice B reason: Administering the client's scheduled antitubercular medications is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should follow the five rights of medication administration and monitor the client for adverse effects and therapeutic outcomes.
Choice C reason: Assisting the client with speech therapy exercises is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires specialized knowledge and skills. The nurse should collaborate with the speech therapist and follow the prescribed plan of care for the client.
Choice D reason: Placing the client on airborne precautions is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should implement the infection control measures and educate the client and the AP about the rationale and the procedures.
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