A nurse manager is receiving report and is faced with the following situations that require interventions. Which of the following should the nurse manager address first?
A client is refusing care from an assistive personnel of the opposite gender
No transport assistance is available to take a client to physical therapy
Two nurses had a heated disagreement about a scheduling issue
Three staff members have called to say they will be absent
The Correct Answer is D
a. A client is refusing care from assistive personnel of the opposite gender:
This situation involves the client's right to refuse care based on personal preferences or cultural beliefs. While it requires attention and respect for the client's wishes, it may not pose an immediate risk to patient care or staff safety.
b. No transport assistance is available to take a client to physical therapy:
This can be resolved by contacting the transportation department or finding an alternative solution, but it is not a critical issue that requires immediate attention.
c. Two nurses had a heated disagreement about a scheduling issue:
While workplace conflicts should be addressed to promote a positive work environment, a heated disagreement about a scheduling issue may not pose an immediate threat to patient care. However, if the disagreement escalates or affects staff morale, it could impact unit functioning and require intervention.
d. Three staff members have called to say they will be absent:
This situation has the most immediate impact on the overall functioning of the unit. Staffing shortages can affect patient care and safety, so it is crucial to address this issue promptly to ensure adequate coverage and maintain the quality of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. A client who is 37 weeks gestation and has an L/S ratio of 2:1:
An L/S (Lecithin/Sphingomyelin) ratio of 2:1 indicates mature fetal lungs, which is a positive indicator. While this client may be nearing term, the presence of mature fetal lungs does not necessarily warrant an interdisciplinary care conference unless there are other complications or high-risk factors present.
b. A client who is 28 weeks gestation and has a negative Coombs's titer:
A negative Coombs's titer suggests that the client does not have antibodies against Rh-positive blood cells, which is a normal finding. At 28 weeks gestation, this client may not require an interdisciplinary care conference unless there are other significant complications or risk factors present.
c. A client who is at 39 weeks gestation and has a negative contraction stress test:
A negative contraction stress test indicates that the fetus is not experiencing distress during uterine contractions, which is a reassuring finding. At 39 weeks gestation, while this client may be nearing term, a negative contraction stress test alone may not warrant an interdisciplinary care conference unless there are other concerning factors present.
d. A client who is at 35 weeks gestation and has a biophysical profile of 6:
A biophysical profile (BPP) of 6 is on the lower end of the scale and may indicate potential fetal compromise or risk. This client may benefit from further evaluation and possibly closer monitoring, which could warrant an interdisciplinary care conference to discuss management and potential interventions.

Correct Answer is C
Explanation
a. Help the AP assist the client with the transfer.
While it is important to instruct the AP to seek assistance when unsure, this does not immediately address the safety of the client during the current incorrect transfer.
b. Demonstrate the proper client transfer technique to the AP.
Demonstrating the proper technique is an important step, but it should come after ensuring the immediate safety of the client. This can be done once the client is safely transferred.
c. Instruct the AP to request assistance when unsure about a task.
Correct. The nurse's first priority should be the safety of the client. By immediately assisting the AP with the transfer, the nurse ensures the client's safety and prevents potential injury.
d. Refer the AP to the facility procedure manual.
Referring the AP to the procedure manual is important for future reference, but it does not address the immediate risk to the client. This action can be taken after ensuring the client's safety and demonstrating the correct technique.
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