The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement?

Wake all the clients and instruct them to go to dining area for medication administration.

Allow the clients to sleep until a third staff person can assist with unit activities.

Explain to the clients that it will be necessary to cooperate until another RN arrives.

Ask the PN to administer medications as clients are awakened so both nurses are available.

Answer and Explanation

The Correct Answer is D

A. Wake all the clients and instruct them to go to dining area for medication administration: Waking all clients at once without adequate staffing may create safety risks and chaos, especially on a mental health unit where supervision is essential.

B. Allow the clients to sleep until a third staff person can assist with unit activities: Delaying medication administration could compromise timely treatment and therapeutic outcomes, making this an unsafe approach.

C. Explain to the clients that it will be necessary to cooperate until another RN arrives: While client communication is important, it does not address the immediate need for safe medication administration and supervision.

D. Ask the PN to administer medications as clients are awakened so both nurses are available: Delegating medication administration to the PN while clients are awakened in a staggered, controlled manner ensures timely delivery of medications, maintains client safety, and allows the nurse to supervise and manage the unit effectively during a staffing shortage.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Encourage positive self accolades for dietary adherence: While supportive reinforcement is helpful for long-term behavior change, it does not address the immediate problem of vomiting and inability to tolerate food and liquids.

B. Determine if the client is over-hydrating to feel satiated: Assessing hydration habits may be part of long-term dietary counseling, but it is not the priority intervention when the client is acutely vomiting and unable to tolerate intake.

C. Maintain the client on an NPO status: Keeping the client NPO prevents further vomiting, reduces the risk of aspiration, and allows the gastrointestinal tract to rest. This is the immediate priority intervention in managing post-bariatric surgery complications such as obstruction or delayed gastric emptying.

D. Administer daily vitamin supplements: Vitamins are important for nutritional maintenance after bariatric surgery, but administering them orally is not appropriate when the client cannot tolerate food or liquids. Nutritional support should be deferred until tolerance improves.

A. Advise the UAP to stop providing care so the nurse can assess the client's condition. B. Determine why the UAP did not notify the nurse of the change in the client's condition. C. Ask the UAP to position the client so the oral medications can be administered. D. Explain to the UAP that changes in a client's condition should be reported immediately.

Correct Answer is A

Explanation

A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.

B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.

C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.

D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.

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Naxlex Comprehensive Predictor Exams

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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