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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F","G"]
Explanation
Rationale for correct choices
• Heart rate 128 beats/minute, sinus tachycardia: Tachycardia signals early compensatory response to hypovolemia or hemorrhagic shock, common with abdominal trauma. Immediate attention is needed to prevent cardiovascular collapse.
• Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A narrow pulse pressure with low systolic BP suggests inadequate stroke volume and poor perfusion, consistent with ongoing internal bleeding.
• Capillary refill 6 seconds: Prolonged refill indicates impaired peripheral perfusion and circulatory compromise, reinforcing concerns of shock.
• No urine output: Absence of urine is a critical marker of inadequate renal perfusion and systemic hypoperfusion, reflecting worsening shock status.
Rationale for incorrect choices
• Temperature 96.9° F (36.1° C): Slightly low but not critical; mild hypothermia is common post-trauma and can be managed after stabilizing perfusion.
• Surgical dressing clean/dry with ecchymosis: Ecchymosis is expected after trauma and surgery, requiring monitoring but not immediate intervention.
• Heart sounds regular, lung sounds clear: No acute cardiopulmonary decompensation detected.
Correct Answer is D
Explanation
A. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours: Intermittent collection is not used for a 24-hour urine test; continuous collection of all urine after the start time is required to accurately measure creatinine clearance.
B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle: This procedure is for a clean-catch or midstream urine specimen, not a 24-hour collection, and does not provide the total volume needed for creatinine clearance.
C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens: Catheterization is unnecessary for routine 24-hour urine collection and increases infection risk. The client can collect urine in a provided container.
D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: Discarding the first void establishes the start of the collection period, and collecting all urine for the next 24 hours ensures accurate measurement of creatinine clearance.
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