A nurse manager is receiving report and is faced with the following situations that require intervention. Which of the following should the nurse manager address first?
Two nurses had a heated disagreement about a scheduling issue.
A client is refusing care from an assistive personnel of the opposite gender.
Three staff members have called to say they will be absent.
No transport assistance is available to take a client to physical therapy.
The Correct Answer is C
- A: While resolving conflicts is important to maintain a healthy work environment, it may not immediately affect patient care and safety.
- B: Client preferences should be respected, but this situation can usually be resolved by reassigning staff without immediate risk to patient safety.
- C: Staff absences can critically impact patient care due to inadequate staffing, which can lead to increased workload for present staff and compromise patient care.
- D: Transport issues, although they need to be addressed, do not usually pose an immediate threat to patient safety compared to inadequate staffing. Physical therapy can often be rescheduled without significant harm to the patient.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Calling the pharmacy for a prescription for the client's partner doesn't necessarily violate client confidentiality as it pertains to the partner's care.
B. Providing a copy of the client's medical record to a third party, the transporting paramedic, breaches confidentiality as it exposes the client's private health information to someone not
involved in direct care.
C. Reporting a client's disposition to the referring provider is part of normal care coordination and doesn't typically violate confidentiality.
D. Informing housekeeping staff about a client's location in a specific unit doesn't divulge confidential health information.
Correct Answer is B
Explanation
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is not the highest priority because this is a chronic condition that does not pose an
immediate threat to the client's health. The nurse should monitor the client's circulation, provide education on foot care, and encourage smoking cessation if applicable.
B. This client is at risk for urinary retention, which can lead to bladder distension,
infection, and renal damage. The nurse should assess the client's bladder, perform a
bladder scan, and notify the provider if indicated. This is the most urgent situation that requires immediate intervention.
C. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is not the highest priority because this is a planned procedure that does not require immediate action. The nurse should prepare the client for chemotherapy, provide emotional support, and teach the client about potential side effects and complications.
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temperature of 38° C (101° F) is not the highest priority because this is a sign of infection that can be managed with antibiotics and infection control measures. The nurse should administer the prescribed antibiotics, monitor the client's vital signs, and
implement contact precautions.
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