The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?
Administered two medications to the same client at the wrong time.
Documented data in the clinical record before assessing client's condition.
Served a diet tray to a client who was NPO for a scheduled procedure.
Changed work assignments without prior approval from charge nurse.
The Correct Answer is B
Choice A Reason: This is not the best action because it is a medication error that can be corrected and prevented by following the rights of medication administration. The nurse manager should counsel the staff nurse and provide education on safe medication practices.
Choice B Reason: This is the best action because it is a serious breach of professional ethics and standards. The nurse manager should report the staff nurse to the PRC for falsifying documentation and compromising client care.
Choice C Reason: This is not the best action because it is a mistake that can be rectified by removing the diet tray and notifying the healthcare provider. The nurse manager should reprimand the staff nurse and review the policy on NPO status.
Choice D Reason: This is not the best action because it is a minor issue that can be resolved by communicating with the charge nurse and other staff members. The nurse manager should remind the staff nurse of the importance of teamwork and collaboration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is A
Explanation
Choice A reason: This client has signs of dehydration and fluid volume deficit, which can lead to shock, a life-threatening condition that occurs when the body's organs are not receiving enough blood flow. The nurse should monitor the client's vital signs, urine output, skin color, and level of consciousness, and report any changes to the physician.
Choice B reason: Initiating enteric precaution procedures is important to prevent the spread of infection, as vomiting and diarrhea may be caused by a contagious pathogen. However, this is not the most important action for the nurse to implement, as it does not address the client's immediate risk of shock.
Choice C reason: Reducing light, noise and temperature may help the client feel more comfortable and reduce nausea, but it is not the most important action for the nurse to implement, as it does not address the client's fluid volume deficit and potential shock.
Choice D reason: Encouraging electrolyte supplements may help replenish the electrolytes lost through vomiting and diarrhea, but it is not the most important action for the nurse to implement, as it may not be enough to restore the fluid balance and prevent shock. The client may need intravenous fluids and medications to correct the dehydration and hypotension.
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