A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to their guardian's room. Which of the following actions should the nurse take?

Check the newborn's identification bracelet with the chart.

Obtain permission from the newborn's guardian.

Respectfully deny the grandparent's request.

Review the newborn's footprint record.

Answer and Explanation

The Correct Answer is C

A. Check the newborn's identification bracelet with the chart: While checking the identification bracelet is important for ensuring the correct identification of the newborn, the request from the grandparent should not be fulfilled without proper identification. It is crucial to prioritize safety and adherence to protocols regarding the newborn's discharge.

B. Obtain permission from the newborn's guardian: Obtaining permission from the newborn's guardian is a necessary step, but the lack of identification from the grandparent still prevents the nurse from allowing the grandparent to take the newborn. The guardian's consent cannot override the identification protocols.

C. Respectfully deny the grandparent's request: Denying the request is the appropriate action in this situation. The nurse must ensure that the newborn is not released to anyone who does not have proper identification, as this is critical for the safety and security of the infant.

D. Review the newborn's footprint record: While reviewing the footprint record can help verify the newborn's identity, it does not address the immediate issue of the grandparent not having an identification bracelet. The nurse's priority should be ensuring that the newborn is only released to authorized individuals with proper identification.

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Correct Answer is B

Explanation

A. Notify the provider: While it is essential to inform the provider about the medication error, the immediate priority is to assess the client's condition first to determine if any adverse effects have occurred. The provider can be notified after ensuring the client is stable.

B. Check the condition of the client: The first action the nurse should take is to assess the client's condition. This includes monitoring for any immediate adverse effects or reactions related to the wrong medication administered. Ensuring the client's safety is the top priority in this situation.

C. Report the occurrence to the unit manager: Reporting the error to the unit manager is an important step in the process but should be done after assessing the client's condition. The immediate focus must be on the client's well-being before addressing administrative aspects of the error.

D. Complete an incident report: Completing an incident report is necessary for documenting the error and ensuring quality improvement measures, but it is not the first action. The nurse must first prioritize the assessment and safety of the client.

A. "The client has a new prescription for incentive spirometry." B. "The client's partner plans to return later today." C. "The client has no living family members." D. "I initiated a consultation by a nutritionist."

Correct Answer is C

Explanation

A. "The client has a new prescription for incentive spirometry.": This statement is more appropriate for the "Assessment" or "Recommendation" section, as it pertains to current treatment plans and interventions rather than the background context of the client's history.

B. "The client's partner plans to return later today.": This information is relevant to the client's social support and engagement but is not critical background information. It may be included in the "Situation" or "Recommendation" sections instead.

C. "The client has no living family members.": This statement is pertinent to the "Background" portion, as it provides important context regarding the client's social situation and support system. Understanding the client's background helps the receiving nurse assess potential psychosocial needs and planning for care.

D. "I initiated a consultation by a nutritionist.": This action relates to ongoing care and assessment of the client's nutritional needs, making it more appropriate for the "Assessment" or "Recommendation" section. It is not part of the historical background needed for effective handoff.

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A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to their guardian's room. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A newly licensed nurse is giving a change-of-shift report using Introductions, Situation, Background, Assessment, Recommendation (ISBAR) to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the "Background" portion of the report?

Correct Answer is C

Explanation

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