78 mmHg

SpO2 96% on room air

Provider Prescriptions

1400

Ceftriaxone 1 gram IV daily

Acetaminophen 650 mg PO every 6 hours for pain

Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply

Medication for elevated temperature

Insertion of NG tube for decompression

Oxygen 2 to 4 L/min via nasal cannula

Insertion of urinary catheter

Evaluation of surgical wound drain

Question Solution

Correct Answer : A,E

Rationale:

A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.

B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.

C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.

D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.

E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.

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A. AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping. B. AP 2-Verifies with nurse the order in which protective equipment should be removed. C. AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room. D. AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing. E. AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit. F. AP 4-Successfully completed skills of simulation including emptying the client's trash can

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

Explanation

Rationale:

A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.

B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.

C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.

D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.

E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.

F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.

A. Nonmaleficence B. Veracity C. Autonomy D. Fidelity

Correct Answer is D

Explanation

Rationale:

A. Nonmaleficence is the principle of doing no harm, which is not directly demonstrated by completing a course.

B. Veracity involves truthfulness, not specifically related to taking a course before transferring units.

C. Autonomy is related to respecting individuals' rights to make their own decisions and is not demonstrated by completing educational requirements.

D. Fidelity refers to being faithful to one’s commitments and promises, which includes taking steps to ensure competency in a new area of practice, thus demonstrating dedication to providing competent care.

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

Explanation

Correct Answer is D

Explanation

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Which skills demonstrated by assistive personnel require immediate follow-up. Select the "3" findings that require immediate follow-up.

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

Explanation

A nurse on a medical-surgical unit has accepted a transfer to the Intensive care unit (ICU). Prior to transfer to the ICU, the nurse completes an online critical care and emergency nursing course. The nurse is demonstrating which of the following ethical principles?

Correct Answer is D

Explanation

A charge nurse is providing an inservice for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment?

A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement?

A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?

A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate?

A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?

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