1. Which client situation requires the most immediate intervention by the charge nurse?
New onset ST segment elevation is observed on the telemetry monitor of a Client admitted with angina
2. As he enters the client’s room, Mr. Young learns that the ED needs to give report on a client to be admitted to the unit as soon as possible. What action should Mr. Young take?
Request that another staff RN obtain the report
3. The UAP enters the room and informs Mr. Young that the confused client with hyponatremia is attempting to climb over the bedrails. How should the charge nurse respond to this situation?
Remain with the client who has angina and assign a PN to monitor the confused client while the UAP obtains a bed alarm
4. The RN reports the vital signs to Mr. Young a T 102, P 112, R 28, and BP 84/42. Who should the charge nurse assign to care for this client?
The newly licensed RN and the staff RN preceptor
5. The PN requests a change in assignment, stating that due to her pregnancy, she is concerned about entering isolation rooms. How should the charge nurse respond?
“What concerns do you have about your pregnancy and this client care situation?”
6. When adhering to the ethic of caring in a leadership role while still maintaining client safety, what is the best action for the charge nurse to implement?
Assign another PN to care for the client and reassign the pregnant PN to other clients
7. A client with which diagnosis and upcoming procedure can best be assigned to this PN, rather than an RN?
Osteoporosis scheduled for a bone mineral density test that day
8. Which tasks can be delegated to the UAP who is assisting the PN and RN in the care of these 4 clients? (Select all)
-Deliver and prepare the meal tray of the client who is in isolation with MRSA-induced pneumonia
-Assist an elderly client who is 3 days postoperative with a bath and change of gown
increase the rate of oxygen being administered
initiating a referral for durable medical equipment and home health care
the RN who is acting as a preceptor for the newly licensed RN
an insulin/potassium infusion to treat DKA
a 56-yo female client with anemia
report any change in mental status, such as disorientation
assist the client in returning to a supine position in the bed
insufficient instruction and supervision by the RN
sinus arrhythmia with rate fluctuation during respiration
contact the healthcare provider (HCP) for a prescription to remove the telemetry and transfer the client
interpretation of the cardiac rhythm
because observation of the procedure will help you provide better care, I will manage our assigned clients while you go
-Experiencing dysphagia following a cerebrovascular accident, which necessitates the use of total parenteral nutrition via a central line
-recovering second day postoperatively from a total hip replacement surgery
schedule time for each nurse on the unit to practice using the insulin pens
offer to repeat a demonstration and allow the PN additional practice time
go with the nurse to observe the difficulty that clients are experiencing with the pens
all clients using insulin pens will measure an accurate dose 100% of the time
The inability of these clients to measure an accurate dose with a syringe
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