Initial Priorities
At the beginning of his shift, Mr. Young identifies several problems that need attention.
1.
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.
CORRECT
This electrocardiogram (ECG) finding indicates ischemic changes which require immediate client assessment
and management to prevent myocardial damage.
B) A client with hyponatremia is becoming increasingly confused, disoriented, and agitated.
INCORRECT
This client does require assessment and intervention to ensure client safety. However, another client requires
immediate intervention.
C) The white blood cell count (WBC) of a client with cellulitis increases from 8,000 to 15,000 mm 3.
INCORRECT
This lab result indicates a worsening of the client's infection, so assessment and intervention are indicated.
However, another client requires immediate intervention.
D) A client starting treatment for tuberculosis develops a productive cough of mucopurulent sputum.
INCORRECT
This is an expected finding for a client with tuberculosis. Therefore, this client does not require immediate
intervention.
Points Earned: 1.0/1.0
Correct Answer(s): A
As he enters the client's room, Mr. Young hears his name paged over the intercom. He learns that the
emergency department needs to give report on a client to be admitted to the medical unit as soon as possible.
2.
What action should Mr. Young take?
A) Return to the nursing unit desk to obtain report.
INCORRECT
This action does not have the highest priority.
B) Take the report over the telephone from the client's room.
INCORRECT
This action does not allow the charge nurse to give his full attention to the unstable client.
C) Request that another staff RN obtain the report.
CORRECT
,Another RN can obtain the report, while the charge nurse gives his full attention to assessment of the unstable
client.
D) Advise the unit secretary to write down the report.
INCORRECT
The unit secretary does not have sufficient knowledge or the expertise to obtain a report on a client.
Points Earned: 0.0/1.0
Correct Answer(s): C
Delegation of Care
While Mr. Young is assessing the client with ECG changes, the client reports that he just experienced an
episode of chest pain and took a dose of nitroglycerine that he brought from home. The UAP enters the room
and informs Mr. Young that the confused client with hyponatremia is attempting to climb over the bedrails.
3.
How should the charge nurse respond to this situation?
A) Instruct the client with angina to call if further assistance is needed, and advise all available staff to help with
the confused client.
INCORRECT
This response does not ensure safe continued care of the client with angina.
B) Remain with the client who has angina and assign an PN to monitor the confused client while the UAP
obtains a bed alarm.
CORRECT
The client with angina and ECG changes remains unstable and requires the expertise of the charge nurse to
assess and manage his care. The PN, assisted by the UAP, can safely monitor a confused client to prevent
injury.
C) Assess the confused client and assign the UAP to take the vital signs of the client with angina.
INCORRECT
The client with angina and ECG changes remains unstable and requires nursing care beyond the scope of the
UAP.
D) Implement fall precautions for the confused client and assign the PN to assess the client with angina.
INCORRECT
This assignment does not demonstrate the best utilization of the available nursing staff.
Points Earned: 0.0/1.0
Correct Answer(s): B
A newly licensed nurse is assigned to the unit, obtains the vital signs of the client with cellulitis whose WBC has
increased from 8,000 to 15,000 mm3. The nurse reports the vital signs to Mr. Young as: T 102° F, P 112, R 28,
and BP 84/42.
, 4.
Who should the charge nurse assign to care for this client?
A) An experienced PN.
INCORRECT
The client’s manifestations require a different level of expertise than that provided by an PN.
B) The newly licensed nurse, assisted by an experienced UAP.
INCORRECT
The newly licensed nurse and the experienced UAP do not have the expertise to care for a client with these
manifestations.
C) The newly licensed nurse and staff nurse preceptor.
CORRECT
The client is exhibiting manifestations of septic shock, a potentially fatal problem. The newly licensed nurse
does not yet have the expertise to respond to this situation independently, and will best obtain the needed
experience by working closely with the staff nurse preceptor.
D) The newly licensed nurse alone.
INCORRECT
The newly licensed nurse does not yet have the expertise to respond to this situation independently.
Points Earned: 1.0/1.0
Correct Answer(s): C
Staff Communication
After the immediate problems are resolved, Mr. Young completes client care assignments for the staff. He
assigns an PN to provide care to a client with pneumonia caused by methicillinresistant staphylococcus aureus
(MRSA). Airborne precautions are required to prevent transmission to healthcare providers and other clients.
The PN requests a change in assignment, stating that, due to her pregnancy, she is concerned about entering
isolation rooms.
5.
How should the charge nurse respond?
A) "As a staff member, you have to care for your fair share of the clients just like everyone else."
INCORRECT
Another response demonstrates a more considerate, caring approach to the concerns voiced by the PN.
B) "No one likes to care for clients in isolation. How do you expect me to change assignments now?"
INCORRECT
Another response demonstrates a more considerate, caring approach to the concerns voiced by the PN.
C) "What concerns do you have about your pregnancy and this client care situation?"
CORRECT
At the beginning of his shift, Mr. Young identifies several problems that need attention.
1.
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.
CORRECT
This electrocardiogram (ECG) finding indicates ischemic changes which require immediate client assessment
and management to prevent myocardial damage.
B) A client with hyponatremia is becoming increasingly confused, disoriented, and agitated.
INCORRECT
This client does require assessment and intervention to ensure client safety. However, another client requires
immediate intervention.
C) The white blood cell count (WBC) of a client with cellulitis increases from 8,000 to 15,000 mm 3.
INCORRECT
This lab result indicates a worsening of the client's infection, so assessment and intervention are indicated.
However, another client requires immediate intervention.
D) A client starting treatment for tuberculosis develops a productive cough of mucopurulent sputum.
INCORRECT
This is an expected finding for a client with tuberculosis. Therefore, this client does not require immediate
intervention.
Points Earned: 1.0/1.0
Correct Answer(s): A
As he enters the client's room, Mr. Young hears his name paged over the intercom. He learns that the
emergency department needs to give report on a client to be admitted to the medical unit as soon as possible.
2.
What action should Mr. Young take?
A) Return to the nursing unit desk to obtain report.
INCORRECT
This action does not have the highest priority.
B) Take the report over the telephone from the client's room.
INCORRECT
This action does not allow the charge nurse to give his full attention to the unstable client.
C) Request that another staff RN obtain the report.
CORRECT
,Another RN can obtain the report, while the charge nurse gives his full attention to assessment of the unstable
client.
D) Advise the unit secretary to write down the report.
INCORRECT
The unit secretary does not have sufficient knowledge or the expertise to obtain a report on a client.
Points Earned: 0.0/1.0
Correct Answer(s): C
Delegation of Care
While Mr. Young is assessing the client with ECG changes, the client reports that he just experienced an
episode of chest pain and took a dose of nitroglycerine that he brought from home. The UAP enters the room
and informs Mr. Young that the confused client with hyponatremia is attempting to climb over the bedrails.
3.
How should the charge nurse respond to this situation?
A) Instruct the client with angina to call if further assistance is needed, and advise all available staff to help with
the confused client.
INCORRECT
This response does not ensure safe continued care of the client with angina.
B) Remain with the client who has angina and assign an PN to monitor the confused client while the UAP
obtains a bed alarm.
CORRECT
The client with angina and ECG changes remains unstable and requires the expertise of the charge nurse to
assess and manage his care. The PN, assisted by the UAP, can safely monitor a confused client to prevent
injury.
C) Assess the confused client and assign the UAP to take the vital signs of the client with angina.
INCORRECT
The client with angina and ECG changes remains unstable and requires nursing care beyond the scope of the
UAP.
D) Implement fall precautions for the confused client and assign the PN to assess the client with angina.
INCORRECT
This assignment does not demonstrate the best utilization of the available nursing staff.
Points Earned: 0.0/1.0
Correct Answer(s): B
A newly licensed nurse is assigned to the unit, obtains the vital signs of the client with cellulitis whose WBC has
increased from 8,000 to 15,000 mm3. The nurse reports the vital signs to Mr. Young as: T 102° F, P 112, R 28,
and BP 84/42.
, 4.
Who should the charge nurse assign to care for this client?
A) An experienced PN.
INCORRECT
The client’s manifestations require a different level of expertise than that provided by an PN.
B) The newly licensed nurse, assisted by an experienced UAP.
INCORRECT
The newly licensed nurse and the experienced UAP do not have the expertise to care for a client with these
manifestations.
C) The newly licensed nurse and staff nurse preceptor.
CORRECT
The client is exhibiting manifestations of septic shock, a potentially fatal problem. The newly licensed nurse
does not yet have the expertise to respond to this situation independently, and will best obtain the needed
experience by working closely with the staff nurse preceptor.
D) The newly licensed nurse alone.
INCORRECT
The newly licensed nurse does not yet have the expertise to respond to this situation independently.
Points Earned: 1.0/1.0
Correct Answer(s): C
Staff Communication
After the immediate problems are resolved, Mr. Young completes client care assignments for the staff. He
assigns an PN to provide care to a client with pneumonia caused by methicillinresistant staphylococcus aureus
(MRSA). Airborne precautions are required to prevent transmission to healthcare providers and other clients.
The PN requests a change in assignment, stating that, due to her pregnancy, she is concerned about entering
isolation rooms.
5.
How should the charge nurse respond?
A) "As a staff member, you have to care for your fair share of the clients just like everyone else."
INCORRECT
Another response demonstrates a more considerate, caring approach to the concerns voiced by the PN.
B) "No one likes to care for clients in isolation. How do you expect me to change assignments now?"
INCORRECT
Another response demonstrates a more considerate, caring approach to the concerns voiced by the PN.
C) "What concerns do you have about your pregnancy and this client care situation?"
CORRECT
