NURSING COMPETENCIES EXAM CONSISTING OF RATIONALE
ANSWERS.
The primary healthcare provider prescribes "bathroom privileges only" for a client
with pulmonary edema. The client becomes irritable and asks the nurse whether it is
really necessary to stay in bed so much. What would be the best reply by the nurse?
- ANSWER Rest helps your body direct energy toward healing
Rationale: The primary healthcare provider prescribes "bathroom privileges only" for
a client with pulmonary edema. The client becomes irritable and asks the nurse
whether it is really necessary to stay in bed so much. What would be the best reply
by the nurse?
A newborn male is circumcised. What is the most essential nursing assessment
during the initial postoperative period? - ANSWER Bleeding
Rationale: The penis is a vascular area, and the infant must be monitored closely for
bleeding. It is too soon to detect signs of infection. Although a circumcised infant
may be uncomfortable, he can be medicated for pain; this type of cry may be
indicative of central nervous system damage. Decreased urine output is usually not a
problem with circumcision.
Which action makes a nurse manager also a nurse leader? - ANSWER Helping
employees reach the highest level of their potential excellence
Rationale: A nurse leader helps employees reach their highest level of potential
excellence and raises their level of expectations. Therefore, to stand out as a nurse
leader, a nurse manager should help with employee development. Implementation of
management skills while hiring and financial accountability for an organization are
roles of a nurse manager, but not a nurse leader. Effective employee selection
indicates a nurse manager but not necessarily a nurse leader.
A registered nurse is teaching a group of student nurses about concepts of triage in
a mass casualty incident. Which statement of the student nurse indicates effective
learning? - ANSWER I will issue green tag to class III, nonurgent clients
Rationale: The disaster triage tag system classifies the triage priority by color and
number. The green tag is for class III clients who are nonurgent or walking wounded.
A black tag is issued to class IV clients who are expected to die. A yellow tag is
issued to clients who do not require urgent treatment and the treatment can be
delayed for some time. A red tag is used for clients who require emergent treatment.
A client, receiving a potassium infusion via a peripheral intravenous (IV) site,
reports a burning sensation above the IV site. What should the nurse do first? -
ANSWER Check the IV access for a blood return
Rationale: Because potassium infusions can be caustic to the vein, a nurse should
check for continued blood return. That finding determines the nurse's next
intervention(s). If blood return is present, then it is appropriate to apply warm
compresses. If there is not a blood return, the infusion needs to be stopped via that
IV site, not slowed. If the potassium infusion cannot be administered, the primary
healthcare provider must be notified so that other means of potassium replacement
can be instituted.
ANSWERS.
The primary healthcare provider prescribes "bathroom privileges only" for a client
with pulmonary edema. The client becomes irritable and asks the nurse whether it is
really necessary to stay in bed so much. What would be the best reply by the nurse?
- ANSWER Rest helps your body direct energy toward healing
Rationale: The primary healthcare provider prescribes "bathroom privileges only" for
a client with pulmonary edema. The client becomes irritable and asks the nurse
whether it is really necessary to stay in bed so much. What would be the best reply
by the nurse?
A newborn male is circumcised. What is the most essential nursing assessment
during the initial postoperative period? - ANSWER Bleeding
Rationale: The penis is a vascular area, and the infant must be monitored closely for
bleeding. It is too soon to detect signs of infection. Although a circumcised infant
may be uncomfortable, he can be medicated for pain; this type of cry may be
indicative of central nervous system damage. Decreased urine output is usually not a
problem with circumcision.
Which action makes a nurse manager also a nurse leader? - ANSWER Helping
employees reach the highest level of their potential excellence
Rationale: A nurse leader helps employees reach their highest level of potential
excellence and raises their level of expectations. Therefore, to stand out as a nurse
leader, a nurse manager should help with employee development. Implementation of
management skills while hiring and financial accountability for an organization are
roles of a nurse manager, but not a nurse leader. Effective employee selection
indicates a nurse manager but not necessarily a nurse leader.
A registered nurse is teaching a group of student nurses about concepts of triage in
a mass casualty incident. Which statement of the student nurse indicates effective
learning? - ANSWER I will issue green tag to class III, nonurgent clients
Rationale: The disaster triage tag system classifies the triage priority by color and
number. The green tag is for class III clients who are nonurgent or walking wounded.
A black tag is issued to class IV clients who are expected to die. A yellow tag is
issued to clients who do not require urgent treatment and the treatment can be
delayed for some time. A red tag is used for clients who require emergent treatment.
A client, receiving a potassium infusion via a peripheral intravenous (IV) site,
reports a burning sensation above the IV site. What should the nurse do first? -
ANSWER Check the IV access for a blood return
Rationale: Because potassium infusions can be caustic to the vein, a nurse should
check for continued blood return. That finding determines the nurse's next
intervention(s). If blood return is present, then it is appropriate to apply warm
compresses. If there is not a blood return, the infusion needs to be stopped via that
IV site, not slowed. If the potassium infusion cannot be administered, the primary
healthcare provider must be notified so that other means of potassium replacement
can be instituted.
