A nurse from the labor and delivery unit is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take first?

Request orientation to the medical-surgical unit.

Refer to the assigned resource nurse regarding client assignments.

Inform the nursing supervisor of the lack of experience on the medical-surgical unit.

Clarify competencies with the medical-surgical charge nurse.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is not the correct choice because requesting orientation to the medical-surgical unit is not the first action the nurse should take. Orientation is a process that takes time and planning, and it may not be feasible or necessary for a temporary assignment. The nurse should first ensure that they are competent to perform the tasks and procedures required on the medical-surgical unit.

Choice B reason: This is not the correct choice because referring to the assigned resource nurse regarding client assignments is not the first action the nurse should take. The resource nurse is a person who can provide guidance and support to the nurse during the shift, but they are not responsible for determining the nurse's competencies or assigning clients. The nurse should first communicate with the charge nurse, who is the leader of the unit and has the authority to assign clients according to the nurse's skills and experience.

Choice C reason: This is not the correct choice because informing the nursing supervisor of the lack of experience on the medical-surgical unit is not the first action the nurse should take. The nursing supervisor is a person who can oversee the staffing and operations of the nursing units, but they are not directly involved in the clinical care of the clients or the education of the staff. The nurse should first consult with the charge nurse, who can assess the nurse's competencies and provide appropriate resources and education.

Choice D reason: This is the correct choice because clarifying competencies with the medical-surgical charge nurse is the first action the nurse should take. The charge nurse is a person who can evaluate the nurse's skills and knowledge, assign clients according to the nurse's level of expertise, and provide orientation and training as needed. The nurse should be honest and proactive in communicating their competencies and learning needs to the charge nurse.

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Correct Answer is C

Explanation

Choice A reason: This response is inappropriate because it violates the client's right to privacy and confidentiality. The nurse should not disclose any information about the client to anyone without the client's consent, unless it is required by law or for the client's safety.

Choice B reason: This response is inappropriate because it shows a lack of accountability and professionalism. The nurse should not dismiss the visitor's concern or pass the responsibility to another nurse. The nurse should either provide the information if they have it or direct the visitor to the appropriate source.

Choice C reason: This response is appropriate because it respects the client's privacy and confidentiality, while also addressing the visitor's concern. The nurse should inform the visitor that they will contact the nurse who is taking care of the client and ask them to come and talk with the visitor.

Choice D reason: This response is inappropriate because it violates the client's privacy and confidentiality. The nurse should not access the client's medical record without a valid reason or the client's consent. The nurse should only check the medical record if they are involved in the client's care or have a need to know the information.

A. Check on a client whose telemetry monitor is continuously beeping. B. Tag a malfunctioning piece of equipment as broken. C. Determine whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula. D. Instruct a client about the use of an incentive spirometer.

Correct Answer is B

Explanation

Choice A reason: This is not the correct choice because checking on a client whose telemetry monitor is continuously beeping is a task that requires nursing judgment and assessment skills. The nurse should not delegate this task to the AP, but rather perform it themselves or notify the health care provider.

Choice B reason: This is the correct choice because tagging a malfunctioning piece of equipment as broken is a task that does not involve direct client care or clinical decision making. The nurse can delegate this task to the AP, who can follow the facility's policy and procedure for reporting and removing faulty equipment.

Choice C reason: This is not the correct choice because determining whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula is a task that involves administering medication and monitoring the client's oxygenation status. The nurse should not delegate this task to the AP, but rather perform it themselves and document the results.

Choice D reason: This is not the correct choice because instructing a client about the use of an incentive spirometer is a task that involves providing client education and evaluating the client's understanding and compliance. The nurse should not delegate this task to the AP, but rather perform it themselves and document the outcomes.

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A nurse from the labor and delivery unit is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take first?

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