The charge nurse on a busy 36-bed medical-surgical floor notices a staff nurse is late again and appears disheveled. The staff nurse's spouse died eight months ago, and the staff nurse has been working extra to pay the mortgage on the house. The staff nurse has exhibited concerning behavior over the past several weeks. The charge nurse has been documenting the staff nurse's behavior.
Accurate documentation in the medication administration record.
Frequent long bathroom breaks
Volunteering to work a double shift
Hand tremors
Reports on slurred speech
Neglect of personal appearance.
Correct Answer : B,D,E,F
Rationale:
A. Accurate documentation is not concerning and indicates safe practice. While there are medication administration concerns in prior notes, the statement “accurate documentation” itself does not reflect immediate risk.
B. Frequent, prolonged bathroom breaks can indicate substance use (e.g., diversion of narcotics), avoidance behaviors, or other issues impacting the nurse’s ability to provide safe care. This behavior is a red flag for impaired practice and requires immediate evaluation.
C. Volunteering to work extra shifts or doubles, although potentially stressful, is not an immediate safety concern. While fatigue could affect performance, the behavior itself is not inherently unsafe.
D. Hand tremors may indicate intoxication, withdrawal, or neurological impairment, all of which can directly compromise patient safety. Tremors combined with other cognitive or behavioral changes are significant red flags.
E. Slurred speech is an indicator of possible substance use, medication effect, or other cognitive impairment. Speech difficulties can impair communication with clients and team members, making this an immediate concern.
F. Neglect of personal appearance, such as wearing wrinkled scrubs and avoiding eye contact, is a behavioral indicator of stress, depression, or potential impairment. While not directly harmful to patients, it signals possible broader concerns affecting professional functioning and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. While ambulation is a routine activity for many patients, clients with acute glomerulonephritis often have edema, hypertension, and fluid retention, which may make frequent ambulation unsafe without assessment and supervision. This is not appropriate for delegation to unlicensed assistive personnel (UAP) without RN guidance.
B. This is appropriate for UAP to implement. Clients with acute glomerulonephritis may require fluid restriction to prevent fluid overload, hypertension, or worsening edema. The RN can instruct the UAP to control access to fluids as part of implementing the care plan.
C. Temperature monitoring is considered an assessment, which is within the RN’s responsibility. Delegating this to UAP may be appropriate for routine vital signs, but in acute glomerulonephritis, changes in temperature could indicate infection or complications, and the RN must be aware of and interpret the findings. Thus, this action is not ideal as primary delegation.
D. Clients with acute glomerulonephritis often have proteinuria, and excess protein intake can worsen kidney injury. Dietary instructions must be provided by the RN or dietitian. UAP can assist with meal delivery but cannot independently instruct on therapeutic diets.
Correct Answer is ["50"]
Explanation
Step 1: Identify the formula
gtt/min = (mL/hr × drop factor) ÷ 60
Step 2: Insert values
= (150 × 20) ÷ 60
Step 3: Calculate
= 3000 ÷ 60
= 50 gtt/min
Final Answer: 50
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