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

Answer and Explanation

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.

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Correct Answer is C

Explanation

a. Green:

Green triage tags are typically used for "walking wounded" or patients with minor injuries who can wait longer for treatment. These patients are considered to have non-life-threatening injuries and can be managed after more critical patients have been stabilized.

b. Yellow:

Yellow triage tags are used for patients with moderate injuries who require medical attention but are not in immediate danger of death. These patients may have significant injuries that require timely treatment but do not have life-threatening conditions.

c. Black:

The black tag is used for patients who are not expected to survive due to severe injuries or critical conditions. In the case of full-thickness burns covering a large percentage of the body (such as 72%), the patient’s prognosis is poor, and immediate care resources should be allocated to those with a higher chance of survival.The black tag indicates that the patient’s injuries are incompatible with life, and comfort measures may be provided, but resuscitation efforts are not a priority.

d. Red:

Red triage tags are used for patients with life-threatening injuries who require immediate medical attention to survive. These patients have critical conditions that require rapid assessment, stabilization, and treatment to prevent further deterioration and improve outcomes.

A. Is the client’s family present so the AP can show them how to turn the client? B. Does the AP have time to change the client’s central IV line dressing after turning her? C. Has data been collected about specific client needs related to turning? D. Has the AP checked the client’s pain level prior to turning her?

Correct Answer is C

Explanation

a. Is the client’s family present so the AP can show them how to turn the client:

While involving the client's family in care can be beneficial for education and support, this assessment does not directly pertain to the AP's ability to provide care or the client's immediate needs.

b. Does the AP have time to change the client’s central IV-line dressing after turning her:

This assessment is relevant to the AP's workload and scheduling, but it does not directly address the client's care needs related to bathing and turning.

c. Has data been collected about specific client needs related to turning:

This assessment is crucial before delegating care. The nurse should ensure that relevant information about the client's condition, including any specific needs or considerations related to turning, has been gathered and communicated to the AP to provide appropriate care.

d. Has the AP checked the client’s pain level prior to turning her:

This assessment is essential to ensure the client's comfort and safety during care activities. Assessing the client's pain level before turning helps prevent exacerbation of pain and ensures that turning is performed with appropriate consideration for the client's comfort.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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