A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit.
Complete the following sentence by using the list of options.
The nurse should instruct the newly licensed nurse to first
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Provide continuous monitoring of this client: Continuous monitoring is essential to ensure the client's safety while in seclusion, particularly given their agitated and potentially harmful behavior.
Obtain provider prescription for seclusion or restraints: It's necessary to ensure that the use of seclusion is appropriately authorized and documented, following the facility's protocol and legal requirements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A,C"}}
Explanation
Time Management: Concerns related to how the nurse manages their time, including the efficiency of their work and how they handle their responsibilities (e.g., frequent trips to the supply room, notes written on small pieces of paper, coming early and staying late to chart).
Delegation: Issues related to the nurse's ability to delegate tasks effectively (e.g., covering other nurses' clients for breaks, which could suggest issues with delegation).
Professional Behavior: Concerns related to the nurse's conduct and adherence to professional standards (e.g., frequent personal phone calls during shifts, not taking breaks, missed prescriptions, covering other nurses' clients without taking breaks).
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