A nurse in a long-term care facility observes an assistive personnel who is incorrectly monitoring a client's blood glucose level. The nurse should report this observation to which of the following personnel first?
Charge nurse
Nurse manager
Nurse supervisor
Risk manager
The Correct Answer is A
In a long-term care setting, concerns related to assistive personnel performance are addressed through the established chain of command. The nurse must first report unsafe or incorrect clinical practice to the immediate supervisory nurse responsible for day-to-day coordination of care. This ensures prompt correction of the issue, immediate client safety, and appropriate delegation or re-education. Escalation to higher administrative roles occurs only if the issue is not resolved at the unit level.
Rationale:
A. The charge nurse is the first-line supervisor responsible for overseeing daily unit operations and delegating tasks to assistive personnel. Reporting incorrect blood glucose monitoring to the charge nurse allows for immediate intervention, correction of technique, and client safety protection. This follows the appropriate chain of command in clinical practice.
B. The nurse manager oversees overall unit administration, staffing, and long-term operations rather than immediate bedside supervision. While the nurse manager may need to be informed of repeated issues, they are not the first point of contact for urgent clinical practice concerns. Immediate correction is best handled at the charge nurse level.
C. The nurse supervisor typically functions in a broader supervisory or administrative role and is not directly responsible for real-time unit-level delegation or correction of staff performance. Reporting directly to this role would bypass the appropriate immediate supervisory structure.
D. The risk manager is responsible for analyzing adverse events and implementing systems-based improvements after an incident has occurred. This role is not involved in immediate clinical supervision or correction of assistive personnel actions. Reporting to risk management is appropriate only after internal resolution and documentation of the event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Interpretation of arterial blood gas (ABG) results in a client with metabolic acidosis involves evaluating acid-base balance, particularly the bicarbonate level as the primary indicator of metabolic status. Metabolic acidosis occurs when there is an accumulation of hydrogen ions or loss of bicarbonate, leading to a decreased blood pH. The respiratory system may attempt compensation by altering carbon dioxide levels, but the defining abnormality remains reduced bicarbonate concentration. Accurate interpretation helps guide treatment of underlying causes such as renal failure, diabetic ketoacidosis, or severe diarrhea.
Rationale:
A. A PaCO₂ of 32 mm Hg reflects respiratory alkalosis or compensatory respiratory response to metabolic acidosis. In metabolic acidosis, the lungs often hyperventilate to “blow off” carbon dioxide in an attempt to raise pH. Therefore, this value represents compensation rather than the primary disorder.
B. A PaO₂ of 64 mm Hg indicates hypoxemia but is not specific to metabolic acidosis. While oxygenation status is important in overall patient assessment, it does not define acid-base imbalance. This value may suggest a respiratory or perfusion issue but is not diagnostic for metabolic acidosis.
C. A bicarbonate (HCO₃) level of 20 mEq/L is consistent with metabolic acidosis because it reflects a primary decrease in base concentration. In conditions such as renal failure or lactic acidosis, bicarbonate is consumed or not adequately regenerated. This reduction is the hallmark laboratory finding in metabolic acidosis.
D. A pH of 7.48 indicates alkalemia, not acidosis. This value is associated with either metabolic alkalosis or respiratory alkalosis depending on associated CO₂ and bicarbonate levels. Therefore, it is inconsistent with the diagnosis of metabolic acidosis.
Correct Answer is ["A","D","E","G"]
Explanation
Assessment of adolescents following severe traumatic events involves identifying manifestations of acute stress reactions, maladaptive coping behaviors, and risk factors for developing Post-traumatic stress disorder or other mental health disorders. Exposure to the sudden death of close family members during a natural disaster is a profound psychological trauma that can lead to intrusive memories, avoidance behaviors, substance use, anxiety, and functional impairment. Nurses must prioritize findings that indicate unresolved trauma, impaired coping, or behaviors that increase risk to the client’s mental and physical health. Early recognition and intervention are essential in preventing worsening psychological distress.
Rationale:
A. Experiencing nightmares requires immediate follow-up because recurrent distressing dreams are a hallmark symptom of trauma-related disorders such as acute stress disorder or PTSD. These nightmares indicate persistent re-experiencing of the traumatic event and may significantly impair sleep quality and emotional regulation. In adolescents, chronic sleep disruption can worsen anxiety, depression, irritability, and concentration difficulties, increasing the need for psychological evaluation and support.
B. Startling easily during thunderstorms may represent hyperarousal related to trauma exposure, but the client reports a preexisting fear of thunderstorms before the tornado occurred. This finding alone does not clearly indicate worsening psychiatric instability or immediate danger. Although it should be monitored, it is not as urgent as indicators of active maladaptive coping or severe trauma-related symptoms.
C. A blood pressure of 122/80 mm Hg is within expected limits for a 16-year-old adolescent and does not indicate acute physiological instability. Mild sympathetic activation can occur in anxious clients, but this value does not suggest hypertensive crisis, shock, or cardiovascular compromise. Therefore, it does not require immediate nursing follow-up.
D. Smoking marijuana to “clear their mind” requires immediate follow-up because it reflects maladaptive coping and substance use following a traumatic event. Adolescents who use substances after trauma are at increased risk for dependency, impaired judgment, worsening depression, and interference with healthy emotional processing. Substance use may also mask worsening psychiatric symptoms and delay appropriate mental health treatment.
E. Witnessing the death of their parents and sibling is a severe traumatic exposure that places the client at high risk for acute stress disorder, PTSD, complicated grief, depression, and suicidal ideation. The violent and sudden loss of immediate family members significantly increases psychological vulnerability, especially in adolescents. This history requires urgent emotional assessment, safety evaluation, and referral for trauma-focused mental health interventions.
F. Attending school regularly is generally a positive adaptive behavior and suggests partial preservation of daily functioning despite recent trauma. Continued participation in academics and maintenance of honor-roll performance indicate some degree of coping and structure. While emotional support is still necessary, this finding alone does not represent an immediate concern requiring urgent follow-up.
G. A friend reporting that the client is “not themselves” requires immediate follow-up because behavioral changes noticed by peers may indicate worsening emotional distress, withdrawal, depression, or altered functioning. Adolescents often minimize symptoms during direct questioning, making collateral observations highly valuable. Sudden personality or behavioral changes after trauma can signal significant psychological deterioration requiring further assessment.
H. A heart rate of 99/min is within the upper range of normal for an adolescent and may occur due to anxiety or emotional stress during the clinic visit. There are no accompanying signs of cardiovascular instability such as hypotension, chest pain, or respiratory distress. Therefore, this finding does not require immediate intervention compared with the psychological concerns present.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.