Nursing Elites

1. Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?

• A. "Make it a stat delivery."?
• B. "Please do it as soon as you can after break."?
• C. "This client is delirious, and we're worried about urinary sepsis."?
• D. "Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately."?

Correct answer: D

Rationale: Effective delegation depends on clear, concise direction that leaves no room for question or interpretation on the part of the one being delegated to. In this scenario, the most appropriate direction is to ensure the urine specimen is collected promptly and delivered to the lab immediately. Choice A is too vague and does not specify the urgency required. Choice B does not emphasize the immediate need for the specimen to be delivered. Choice C introduces unnecessary medical information that is beyond the scope of a nursing assistant and may cause confusion. Therefore, choice D is the correct answer as it provides clear instructions for immediate action without room for misunderstanding.

2. A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?

• A. Report the incident to the nursing supervisor
• B. Confront the nurse who gave the enema and inform the nurse that she may face charges of battery
• C. Tell the client that the nurse did the right thing in giving the enema
• D. Contact the client's health care provider

Correct answer: A

Rationale: Battery is any intentional touching of a client without the client's consent, which violates the client's rights. If a nurse discovers such an incident, they should report it to the nursing supervisor. Confronting the nurse and threatening charges of battery could lead to unnecessary conflict. Telling the client that the nurse did the right thing is incorrect as it goes against the client's wishes. While the health care provider may need to be notified eventually, the first step should be reporting the incident to the nursing supervisor to address the violation appropriately.

3. The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:

• A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
• B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
• C. request that the family have a seat in the station rather than stand while awaiting its loved one.
• D. request that the family wait for its loved one in the Emergency Department waiting room.

Correct answer: A

Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality. Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality. Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information. Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.

4. During the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) listed and the number present in the narcotic drawer. The nurse's first action should be to:

• A. Notify the hospital pharmacist
• B. Notify the nursing supervisor
• C. Notify the Board of Nursing
• D. Notify the director of nursing

Correct answer: B

Rationale: The first action the nurse should take is to report the finding to the nursing supervisor and follow the chain of command. Notifying the nursing supervisor allows for immediate action within the facility to address the discrepancy. If it is found that the pharmacy is in error, then notifying the hospital pharmacist (Choice A) would be appropriate. Choices C and D, notifying the Board of Nursing and the director of nursing, are not the initial steps to take. These options may be necessary if theft is suspected or if the facility's internal response is inadequate. Therefore, they are incorrect answers.

5. Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?

• A. Nurse Christine should offer to give medications to Nurse Ann's other two clients.
• B. Nurse Christine should inform their supervisor that assignments may need to be changed.
• C. Nurse Christine should ask other nurses who might be able to help Nurse Ann.
• D. Nurse Ann should try not to burden other nurses and continue caring for her assigned clients.

Correct answer: B

Rationale: In this situation, when Nurse Ann informs Nurse Christine that a client's status is declining and she needs to attend to them, the most appropriate action for Nurse Christine is to inform their supervisor that assignments may need to be changed. By informing the supervisor, necessary adjustments can be made to ensure proper care for all clients. Offering to give medications to Nurse Ann's other two clients (choice A) may not address the underlying issue of a declining client and could lead to a delay in care. Asking other nurses for help (choice C) might not be the most efficient solution, as the supervisor is responsible for reassigning tasks. Nurse Ann continuing to care for all her assigned clients (choice D) may compromise the quality of care provided to the declining client and may spread her too thin, impacting all clients negatively.

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