A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?

Obtain the client's legal records for power of attorney.

Give analgesic medications as needed (PRN).

Discontinue the intravenous infusion.

Ask the palliative care team to speak with the client.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is not the first priority because it does not address the client's immediate needs. The nurse should obtain the client's legal records for power of attorney, but this can be done later.

Choice B Reason: This is a good action because it helps relieve the client's pain and discomfort. The nurse should give analgesic medications as needed (PRN), but this is not enough to meet the client's holistic needs.

Choice C Reason: This is not an appropriate action because it may cause harm to the client. The nurse should not discontinue the intravenous infusion without a valid reason and a healthcare provider's order.

Choice D Reason: This is the best action because it respects the client's wishes and provides him with quality end-of-life care. The nurse should ask the palliative care team to speak with the client and offer him emotional, spiritual, and physical support.

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Correct Answer is A

Explanation

Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.

Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.

Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that

increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.

Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.

A. Evaluate the nurse's performance using standards of practice, citing both strengths and weaknesses with emphasis on ways to improve practice. B. Focus on the strengths of the staff nurse; discuss any weaknesses verbally but avoid documenting the nurse's negative behaviors. C. Emphasize the nurse's areas of weakness in light of the inconsistent performance observed and discuss how to improve in each of these areas. D. Focus on a discussion of how the inconsistency in the staff nurse's performance disrupts the routine of all of the staff members on the unit.

Correct Answer is A

Explanation

Choice A Reason: This intervention is the most appropriate and effective for the nurse-manager to employ, as it provides clear and objective feedback to the staff nurse based on professional criteria, and encourages a positive and constructive approach to enhance the nurse's performance and development.

Choice B Reason: This intervention is not advisable, as it may create a false impression of the staff nurse's performance and fail to address the underlying issues or problems. Documenting the nurse's negative behaviors is important for accountability and improvement purposes, and avoiding it may expose the nurse manager to legal or ethical risks.

Choice C Reason: This intervention is not optimal, as it may demoralize or discourage the staff nurse and create a negative or hostile work environment. Focusing only on the areas of weakness may overlook the strengths and potential of the staff nurse, and may not foster a supportive and collaborative relationship between the nurse- manager and the staff nurse.

Choice D Reason: This intervention is not relevant, as it may divert the attention from the staff nurse's performance and shift the blame to external factors. Discussing how the inconsistency in the staff nurse's performance disrupts the routine of all of the staff members on the unit may not help the staff nurse identify and address their own areas of improvement, and may cause resentment or conflict among the team.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

In evaluating a staff nurse who demonstrates inconsistent performance, which intervention should the nurse- manager employ?

Correct Answer is A

Explanation

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