A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?

Making a clinical decision in the patient's best interest.

Making a clinical decision based on previous shift assessments.

Making an ethical clinical decision

Making an informed clinical decision

Answer and Explanation

The Correct Answer is B

A. Making a clinical decision in the patient's best interest: Making decisions in the patient’s best interest is an essential part of nursing practice and demonstrates good clinical judgment.

B. Making a clinical decision based on previous shift assessments. Nursing assessments should be conducted for each shift, as a patient’s condition can change rapidly. Relying on previous assessments without reassessing can lead to missed changes in the patient’s status, potentially causing harm.

C. Making an ethical clinical decision. Ethical decision-making is an integral part of nursing practice and aligns with professional standards. There is no need for intervention if the decision is ethical.

D. Making an informed clinical decision. Informed clinical decision-making is based on current patient data, clinical guidelines, and critical thinking. This is a correct approach to nursing care and does not require intervention.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Give the medication in the morning daily. Montelukast (a leukotriene receptor antagonist) is given once daily in the evening for long-term asthma control. If prescribed for allergic rhinitis, it can be given in the morning.

B. Administer the medication 2 hours before exercise. Montelukast is not a rescue medication but a maintenance drug. However, it can be prescribed for exercise-induced bronchospasm and is taken at least 2 hours before exercise when used for that purpose.

C. Administer the granules mixed with 20 ounces of water. Montelukast granules should be mixed with a small amount of soft food (e.g., applesauce, mashed carrots) or breast milk/formula but not a large volume of liquid.

D. Give the medication at the onset of wheezing. Montelukast is not a quick-relief medication and does not work immediately. Short-acting bronchodilators (e.g., albuterol) should be used for acute wheezing.

A. Stage I Pressure Ulcer B. Stage III Pressure Ulcer C. Healing Stage III Pressure Ulcer D. Healing Stage II Pressure Ulcer

Correct Answer is C

Explanation

A. Stage I Pressure Ulcer: A Stage III pressure ulcer does not regress to a Stage I as it heals. It retains its original staging classification.

B. Stage III Pressure Ulcer: While the ulcer was originally Stage III, documenting it this way without specifying healing progress does not accurately reflect its current condition.

C. Healing Stage III Pressure Ulcer: Pressure ulcers are documented at their worst stage, even as they heal. The correct terminology includes "healing" to show improvement.

D. Healing Stage II Pressure Ulcer: A Stage III ulcer does not become a Stage II ulcer as it heals; instead, it is called a healing Stage III pressure ulcer.

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A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide to the client's parents on administering the medication?

Correct Answer is A

Explanation

The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?

Correct Answer is C

Explanation

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Which action should the nurse take when using critical thinking to make clinical decisions?

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?

Convert from Fahrenheit to Celsius: 98.6