HESI: Management of a Medical Unit and Rationale | Questions and Answers with complete solution

Which client situation requires the most immediate intervention by the charge nurse? a) New onset ST segment elevation is observed on the telemetry monitor of a client admitted with angina. b) A client with hyponatremia is becoming increasingly confused, disoriented, and agitated. c) The white blood cell (WBC) count of a client with cellulitis increases from 8,000mm3 (8.5 109/L) to15,000 mm3 (15 109/L). d) A client starting treatment for tuberculosis develops a productive cough of mucopurulent sputum. - a) New onset ST segment elevation is observed on the telemetry monitor of a client admitted with angina. - This electrocardiogram (ECG) finding indicates ischemic changes that require immediate client assessment and management to prevent myocardial damage. (Potentially life threatening change in condition.) Upon entering the problematic client's room, the charge nurse is paged to take report on a client being admitted to the medical unit. What action should the charge nurse take? a) Return to the nursing unit desk to obtain the report. b) Take the report over the telephone from the client's room. c) Request that another staff RN obtain the report. d) Advise the unit secretary to write down the report. - c) Request that another staff RN obtain the report. - Another registered nurse (RN) can obtain the report, while the charge nurse gives his full attention to assessment of the unstable client. This is appropriate delegation. While the charge nurse is assessing the client with ECG changes, the client admits to having chest pain. The client also reports taking a dose of nitroglycerin that was brought from home. The UAP enters theroom and informs charge nurse that the confused client with hyponatremia is attempting to climb over the bedrails. What is the priority for the charge nurse in this situation? a) Instruct the client with angina to call if further assistance is needed, and assist the UAP in caring for the confused client. b) Remain with the client who has angina and assign a practical nurse (PN) to monitor the confused client while the UAP obtains a bed alarm. c) Assess the confused client and assign the UAP to take the vital signs of the client with angina. d) Implement fall precautions for the confused client and assign the PN to assess the client with angina. - b) Remain with the client who has angina and assign a practical nurse (PN) to monitor the confused client while the UAP obtains a bed alarm. - The client with angina and ECG changes remains unstable and requires the expertise of the charge nurse to assess and manage his care. The practical nurse (PN), assisted by the unlicensed assistive personnel (UAP), can safely monitor a confused client to prevent injury. A newly-licensed nurse admits a client with cellulitis whose WBC count has increased from 8,000 mm3 (8.5 109/L) to 15,000 mm3 (15.0 109/L). The nurse reports the vital signs to the charge nurse as Temperature 102° F (38.8° C) , Pulse 112 beats/minute, Respirations 28 breaths/minute, and Blood Pressure 84/42 mm/Hg. Who should the charge nurse assign to care for this client? a) An experienced practical nurse (PN). b) The newly-licensed nurse, assisted by an experienced UAP. c) The newly-licensed nurse and the staff nurse preceptor. d) The newly-licensed nurse alone. - c) The newly-licensed nurse and the staff nurse preceptor.