A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?

Obtain the client's legal records for power of attorney.

Give analgesic medications as needed (PRN).

Discontinue the intravenous infusion.

Ask the palliative care team to speak with the client.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is not the first priority because it does not address the client's immediate needs. The nurse should obtain the client's legal records for power of attorney, but this can be done later.

Choice B Reason: This is a good action because it helps relieve the client's pain and discomfort. The nurse should give analgesic medications as needed (PRN), but this is not enough to meet the client's holistic needs.

Choice C Reason: This is not an appropriate action because it may cause harm to the client. The nurse should not discontinue the intravenous infusion without a valid reason and a healthcare provider's order.

Choice D Reason: This is the best action because it respects the client's wishes and provides him with quality end-of-life care. The nurse should ask the palliative care team to speak with the client and offer him emotional, spiritual, and physical support.

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Correct Answer is C

Explanation

Choice A Reason: Cautioning the nurse that one more tardiness will result in probational employment is not the best approach because it is too punitive and does not address the underlying cause of the tardiness. The nurse manager should first try to understand why the nurse is late and offer support or guidance if needed.

Choice B Reason: Offering to switch the nurse's shift assignments to afternoons or evenings is not the best approach because it may not solve the problem of tardiness and may create resentment among other staff members who have to adjust their schedules. The nurse manager should respect the nurse's preferences and availability but also hold the nurse accountable for fulfilling their responsibilities.

Choice C Reason: This is the best approach because it communicates clearly and respectfully what is expected of the nurse and why it is important for them to be punctual. The nurse manager should also provide feedback and recognition when the nurse improves their attendance.

Choice D reason: Having the nurse sign a copy of the hospital employee attendance policy is not the best approach because it may imply that the nurse is unaware or indifferent to the policy. The nurse manager should assume that the nurse knows and agrees with the policy, but may need some assistance or motivation to follow it.

A. Provide client with resources and discharge teaching B. Educate the clients about prescribed dietary changes. C. Establish blood pressure parameters for client monitoring D. Reinforce diet teaching for discharge to home

Correct Answer is D

Explanation

Choice A Reason: This action requires assessment and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for providing client education and ensuring that the client understands the discharge instructions.

Choice B Reason: This action requires teaching and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for educating the clients about their prescribed dietary changes and assessing their learning needs and readiness.

Choice C Reason: This action requires critical thinking and decision-making skills, which are beyond the scope of practice of the PN. The nurse is responsible for establishing the blood pressure parameters for client monitoring and adjusting them as needed.

Choice D Reason: This action can be safely delegated to the PN, as it involves reinforcing previous teaching done by the nurse. The PN can review the diet information with the client and answer any questions they may have.

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Naxlex Comprehensive Predictor Exams

A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?

Correct Answer is C

Explanation

The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the practical nurse (PN)?

Correct Answer is D

Explanation

In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

The nurse manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse manager respond?

A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?

When triaging emergency room clients, which client should the nurse assess first?

A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?