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1. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) working in the diabetic clinic?
- A. Measure the ankle-brachial index.
- B. Check for changes in skin pigmentation.
- C. Assess for unilateral or bilateral foot drop.
- D. Ask the patient about symptoms of depression.
Correct answer: A
Rationale: The correct answer is A: Measure the ankle-brachial index. This task involves using a Doppler ultrasound device to assess blood flow, which can be safely delegated to UAP. Choices B, C, and D require a higher level of assessment and interpretation that should be performed by licensed nursing staff. Checking for changes in skin pigmentation (B) and assessing for foot drop (C) involve more complex assessments that require nursing judgment. Asking about symptoms of depression (D) involves a psychosocial assessment, which should be performed by licensed personnel qualified to address mental health concerns.
2. When a nurse observes a fellow nurse preparing an incorrect dose of medication, what is the best action to take?
- A. Ignore the error
- B. Administer the medication anyway
- C. Correct the error without informing the nurse
- D. Report the error to the supervisor immediately
Correct answer: D
Rationale: The best action to take when a nurse observes a fellow nurse preparing an incorrect dose of medication is to report the error to the supervisor immediately. Reporting the error is crucial to ensure patient safety and prevent any potential harm. Ignoring the error (Choice A) is not appropriate as it puts the patient at risk. Administering the medication anyway (Choice B) could harm the patient. Correcting the error without informing the nurse (Choice C) does not address the root cause of the issue, which should be brought to the attention of the supervisor for proper investigation and resolution.
3. A client experiences difficulty breathing after the change of shift. The nurse on duty discovers that the IVFs were infusing at a rate 10 times the calculated normal. After notifying the physician and correcting the rate, what should be the next step in the client's care?
- A. Notify family
- B. Discipline the previous nurse
- C. Complete an incident report
- D. Obtain legal consultation
Correct answer: C
Rationale: The correct next step in the client's care after notifying the physician and correcting the rate of IVFs is to complete an incident report. This report is essential for documenting the adverse event, analyzing the cause, and implementing preventive measures to avoid similar incidents in the future. Notifying the family, disciplining the previous nurse, and obtaining legal consultation are not immediate priorities in this situation. Family notification may follow the incident report, disciplining the previous nurse is a separate administrative process, and legal consultation is usually not required for a medical error corrected promptly.
4. A registered nurse (RN) who usually uses public transportation has not renewed her driver�s license. During a recent car trip with a friend, she took over driving when her friend became tired. Which of the following is true?
- A. She has acted in a professional manner.
- B. She may lose her RN license for driving without a license.
- C. She should renew her driver�s license as soon as possible.
- D. Under the circumstances, she will not be faulted for driving without a license.
Correct answer: B
Rationale: Driving without a license is deemed an unprofessional and illegal behavior for which a nurse may lose his or her license.
5. What is the main goal of discharge planning?
- A. To ensure that patients are discharged as quickly as possible
- B. To prevent hospital readmissions
- C. To educate patients about their medications
- D. To transition patients from one level of care to another
Correct answer: B
Rationale: The main goal of discharge planning is to prevent hospital readmissions by ensuring patients have a clear and effective plan for post-discharge care. This includes coordinating follow-up appointments, medication management, and providing necessary support services to promote a successful transition from the hospital to home or another care setting. Choices A, C, and D are incorrect because discharge planning is not primarily about speedy discharge, medication education, or transitioning between care levels; its main focus is on preventing readmissions through comprehensive post-discharge care.
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