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After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range:

International Normalized Ratio [0.8 to 1.1]

Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]

The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).

The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.

The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).

The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).

Answer and Explanation

The Correct Answer is A

Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.

Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.

Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that

increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.

Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A Reason: The initial administration of the analgesic is not an intervention that the charge nurse should counsel the nurse about. The opioid analgesic was prescribed by the healthcare provider and was appropriate for the postoperative pain management of the client.

Choice B Reason: The decision regarding when to call the healthcare provider is an intervention that the charge nurse should counsel the nurse about. The nurse should have called the healthcare provider as soon as the client's

respiratory rate decreased to 6 breaths/minute, which is a sign of opioid-induced respiratory depression. Waiting for another 30 minutes until the respiratory rate decreased to 4 breaths/minute could have put the client at risk of hypoxia, brain damage, or death.

Choice C Reason: The documentation of the client's respiratory rate is not an intervention that the charge nurse should counsel the nurse about. The nurse documented the client's respiratory rate accurately and timely, which is part of the standard of care and legal responsibility of the nurse.

Choice D Reason: The administration of naloxone via IV is not an intervention that the charge nurse should counsel the nurse about. Naloxone is an opioid antagonist that reverses the effects of opioids and restores normal respiration. Administering naloxone via IV is the fastest and most effective way to treat opioid-induced respiratory depression.

A. Caution the nurse that one more tardiness will result in probational employment. B. Offer to switch the nurse's shift assignments to afternoons or evenings. C. Stress the expectation that the nurse will arrive on time for all scheduled shifts. D. Have the nurse sign a copy of the hospital employee attendance policy.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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

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Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?