The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement?

Wake all the clients and instruct them to go to dining area for medication administration.

Allow the clients to sleep until a third staff person can assist with unit activities.

Explain to the clients that it will be necessary to cooperate until another RN arrives.

Ask the PN to administer medications as clients are awakened so both nurses are available.

Answer and Explanation

The Correct Answer is D

A. Wake all the clients and instruct them to go to dining area for medication administration: Waking all clients at once without adequate staffing may create safety risks and chaos, especially on a mental health unit where supervision is essential.

B. Allow the clients to sleep until a third staff person can assist with unit activities: Delaying medication administration could compromise timely treatment and therapeutic outcomes, making this an unsafe approach.

C. Explain to the clients that it will be necessary to cooperate until another RN arrives: While client communication is important, it does not address the immediate need for safe medication administration and supervision.

D. Ask the PN to administer medications as clients are awakened so both nurses are available: Delegating medication administration to the PN while clients are awakened in a staggered, controlled manner ensures timely delivery of medications, maintains client safety, and allows the nurse to supervise and manage the unit effectively during a staffing shortage.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","E","F"]

Explanation

Rationale for Correct Choices:

The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.

Rationale for Incorrect Choices:

Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.

A. Palpate flank area. B. Assess perineal area. C. Measure abdominal girth. D. Observe insertion site.

Correct Answer is D

Explanation

A. Palpate flank area: Flank assessment may help detect kidney tenderness or infection but is not the primary focus for routine suprapubic catheter care unless complications are suspected.

B. Assess perineal area: The suprapubic catheter bypasses the perineal route, so routine perineal assessment is less critical for catheter management, though general hygiene remains important.

C. Measure abdominal girth: Abdominal girth measurement is useful for detecting ascites or abdominal distention but is not directly relevant to monitoring a suprapubic catheter.

D. Observe insertion site: Regular inspection of the catheter insertion site is essential to detect signs of infection, leakage, irritation, or improper placement. This assessment helps ensure catheter function and prevents complications, making it the priority during home visits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","E","F"]

Explanation

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is D

Explanation

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?