A charge nurse in the emergency department is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is appropriate for the float nurse?
Administer IV nitroglycerin to a client who is experiencing chest pain.
Complete a SAD PERSONS assessment scale for a client who has attempted suicide.
Set up a trauma room for an incoming client who was in a motor-vehicle crash.
Perform a urinary catheterization for a client who has experienced a cerebrovascular accident.
The Correct Answer is D
Choice A reason: Administering IV nitroglycerin to a client who is experiencing chest pain is not an appropriate assignment for the float nurse, as it requires advanced cardiac knowledge and skills that the nurse may not have. The charge nurse should assign this task to a nurse who is experienced in the emergency department.
Choice B reason: Completing a SAD PERSONS assessment scale for a client who has attempted suicide is not an appropriate assignment for the float nurse, as it requires mental health expertise and training that the nurse may not have. The charge nurse should assign this task to a nurse who is qualified in psychiatric nursing.
Choice C reason: Setting up a trauma room for an incoming client who was in a motor-vehicle crash is not an appropriate assignment for the float nurse, as it requires emergency preparedness and competence that the nurse may not have. The charge nurse should assign this task to a nurse who is familiar with the trauma protocols and equipment.
Choice D reason: Performing a urinary catheterization for a client who has experienced a cerebrovascular accident is an appropriate assignment for the float nurse, as it is a basic nursing skill that the nurse should have learned and practiced in the medical-surgical unit. The charge nurse should assign this task to the float nurse as long as the nurse is comfortable and confident with the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is an incorrect action by the unit nurse. Alcohol-based hand sanitizer is not effective against Clostridium difficile spores, which can cause severe diarrhea and colitis. The nurse should wash their hands with soap and water after removing gloves to prevent the spread of the infection.
Choice B reason: This is a correct action by the unit nurse. Wearing goggles when emptying the bedpan of liquid stool is a standard precaution that protects the nurse's eyes from exposure to body fluids. The nurse should also wear gloves and a gown when handling the bedpan.
Choice C reason: This is a correct action by the unit nurse. Placing the client in contact precautions is an appropriate measure for clients who have Clostridium difficile. Contact precautions prevent direct or indirect transmission of the infection through contact with the client or the client's environment. The nurse should use a single room or cohort the client with another client who has the same infection.
Choice D reason: This is a correct action by the unit nurse. Cleaning contaminated equipment with bleach-based solution is an effective way to kill Clostridium difficile spores, which can survive on surfaces for a long time. The nurse should follow the manufacturer's instructions for the dilution and contact time of the bleach solution.
Correct Answer is B
Explanation
Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.
Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.
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