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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because the client's vital signs indicate that she is hypovolemic and dehydrated due to the leakage of gastric contents from the anastomosis site. The nurse should replace fluids intravenously to prevent shock and electrolyte imbalance.
Choice B Reason: Recording the amount of daily wound drainage is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should monitor the wound drainage for signs of infection and report any changes to the physician.
Choice C Reason: Assessing skin condition and turgor for breakdown is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should assess the skin for signs of dehydration and pressure ulcers and provide appropriate skin care.
Choice D Reason: Turning every 2 hours around the clock from side-to-side is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should turn the client to prevent complications such as pneumonia and atelectasis but also consider the client's comfort and pain level.
Correct Answer is B
Explanation
Choice A Reason: Waiting until the end of the second week to see if the orientee is able to complete her assignments is not the best action for the charge nurse to take. This would delay providing feedback and support to the orientee, who may feel frustrated and discouraged by her performance. The charge nurse should intervene as soon as possible to help the orientee improve her skills and confidence.
Choice B Reason: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee is the best action for the charge nurse to take. This would provide the orientee with a role model and a mentor who can guide her through the daily tasks, share tips and tricks, and offer constructive feedback and encouragement. The orientee would benefit from learning from someone who has mastered the workflow and expectations of the unit.
Choice C Reason: Informing the supervisor that for client safety this nurse should be assigned to a slower-paced unit is not the best action for the charge nurse to take. This would imply that the orientee is incompetent and unsuitable for the unit, which may damage her self-esteem and motivation. The charge nurse should first try to help the orientee adjust to the unit and develop her competencies before considering a transfer.
Choice D Reason: Talking to the orientee and asking her if she has considered working in a less stressful environment is not the best action for the charge nurse to take. This would suggest that the charge nurse has given up on the orientee and does not believe in her potential. The charge nurse should first try to understand the challenges and needs of the orientee and provide appropriate guidance and support before suggesting alternative career options.
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