The nurse obtains verbal prescriptions from the healthcare provider for an antianginal, telemetry, and STAT serum analysis for cardiac isoenzymes, after reading back the prescriptions to the healthcare provider of a client's upper gastric burning, left jaw pain, and nausea. Which intervention is most important for the nurse to implement?

Initiate telemetry and assess the client's cardiac rhythm.

Document description of nausea and administer the antiemetic.

Submit electronic prescriptions to the pharmacy and laboratory.

Obtain the client's 10-point score for radiating jaw pain.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention, as the client's symptoms suggest a possible myocardial infarction (MI) or angina. The nurse should initiate telemetry and assess the client's cardiac rhythm for any signs of ischemia, injury, or infarction. The nurse should also administer the antianginal medication as prescribed and monitor the client's response.

Choice B reason: This is a relevant intervention, as nausea is a common symptom of MI or angina, especially in women. The nurse should document the description of nausea and administer the antiemetic medication as prescribed. The nurse should also assess the client's abdominal pain and rule out other causes such as gastritis or ulcer.

Choice C reason: This is a necessary intervention, as the verbal prescriptions need to be submitted electronically to the pharmacy and laboratory for processing and verification. The nurse should also document the verbal prescriptions and the read-back process in the client's record. However, this is not the most important intervention, as it can be done after the client's condition is stabilized.

Choice D reason: This is not a priority intervention, as the client's jaw pain is likely related to the cardiac problem and not to a separate issue. The client's pain should be assessed using a standard scale such as the numeric rating scale or the Wong-Baker FACES scale. The nurse should also administer analgesics as prescribed and monitor the client's pain level.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A reason: Transcription of the healthcare provider's treatment plan is not a task that can be delegated to a PN, as it requires nursing judgment and documentation. The charge nurse should perform this task and verify the orders with the provider.

Choice B reason:A subclavian catheter dressing change is a sterile procedure involving central line care, which is considered an advanced skill typically performed by an RN. Many facilities do not allow PNs to perform this due to the risk of infection and complications.

Choice C reason: The admission assessment is not a task that can be delegated to a PN, as it involves collecting and analyzing data from multiple sources. The charge nurse or the registered nurse should perform this task and document the findings.

Choice D reason: PNs are trained and authorized to insert Foley catheters, which is within their scope of practice. Although the patient has septicemia, catheter insertion is a task-based procedure that does not require critical decision-making, making it an appropriate assignment for a PN.

A. Ask the nurse why she thinks there is no need for an in-service program about these emergencies. B. Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies. C. Choose to send another nurse who is more receptive because the older nurse is not interested. D. Inform the older nurse that in-service is not optional and her scheduled attendance is mandatory.

Correct Answer is B

Explanation

The correct answer is B. Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.

Choice A: Ask the nurse why she thinks there is no need for an in-service program about these emergencies.

This response might come across as confrontational and could potentially escalate the situation. It puts the nurse on the defensive and does not foster a collaborative environment. Instead of addressing the nurse’s concerns, it questions her judgment, which might not be the most effective way to manage the situation.

Choice B: Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.

This approach is the most constructive and supportive. It opens a dialogue, allowing the nurse to express her concerns and feel heard. By discussing the importance of bioterrorism preparedness and finding ways to address any issues she might have, the nurse-manager can foster a more positive and cooperative atmosphere. This method aligns with effective communication and conflict resolution strategies in healthcare management.

Choice C: Choose to send another nurse who is more receptive because the older nurse is not interested.

This option avoids addressing the underlying issue and could be seen as dismissive. It does not resolve the nurse’s concerns and might lead to further dissatisfaction or disengagement. Additionally, it does not promote a culture of continuous learning and improvement, which is crucial in healthcare settings.

Choice D: Inform the older nurse that in-service is not optional and her scheduled attendance is mandatory.

While this response is direct and enforces the rules, it lacks empathy and does not address the nurse’s concerns. It might lead to resentment and a negative work environment. Effective management involves understanding and addressing employees’ concerns, not just enforcing rules.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?

Correct Answer is D

Explanation

The nurse-manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?

Correct Answer is B

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the PN?

A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?

The charge nurse is making assignments for a 15-bed skilled nursing unit with the staff of one nurse, two practical nurses (PN), and two unlicensed assistive personnel (UAP). Which client should be assigned to the PN?