Nursing Competencies

The nurse is caring for a hospitalized immunosuppressed client. Which interventions will be beneficial for safe and effective care of this client?

Avoid using supplies from common areas Encourage activity at an appropriate level Use alcohol-based hand rubs before touching the client Rationale: Supplies from common areas should not be used for neutropenic clients to prevent contracting infection. Physical activity at a level appropriate for client's condition should be encouraged to promote health. Alcohol-based hand rubs should be used before touching the client to decrease the risk of infection. Immunosuppressed clients should avoid eating raw fruits and vegetables; they should eat low-bacteria diet. Gauge-containing wound dressings should be changed on a daily basis, not on alternative days, to prevent infection.

A newborn male is circumcised. What is the most essential nursing assessment during the initial postoperative period?

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.

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?

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.

Which action makes a nurse manager also a nurse leader?

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.

Neuroleptic malignant syndrome develops in a client who is taking a conventional antipsychotic medication. What signs and symptoms does the nurse expect?

Hyperpyrexia, Increased muscle tone, Respiratory depression Rationale: Neuroleptic malignant syndrome is caused by dopamine blockade in the hypothalamus, precipitated by antipsychotic medications. The hypothalamus activates, controls, and integrates many of the involuntary functions necessary for living. Signs and symptoms of a problem in this area include increased body temperature (hyperpyrexia), increased muscle tone, and respiratory depression. Blurred vision is a side effect of anticholinergics. Lip-smacking is associated with tardive dyskinesia.

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?

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.

Which characteristics should a nurse focus on to become an effective transformational leader?

Inspiring a shared vision Improving interpersonal skills Being able to motivate the nursing staff Rationale: Having a shared vision helps effective transformational leaders and their teams become inspired and committed to a shared goal. Being an effective transformational leader depends on one's interpersonal skills; improving these can help in interactions with the staff. The ability to motivate the nursing staff is also important for a transformational leader because this helps one reach desired goals and improve performance. Acquiring a mentor is not a requirement of transformational leadership. Upgrading one's self-knowledge is beneficial for a nurse leader in decision making.

A healthcare team is caring for a population according to the functional model of nursing. Which healthcare team member is most appropriate for the delegation of hygiene care?

Nursing assistant Rationale: The nursing assistant is eligible for performing activities such as providing hygiene care and determining vital signs. Unit secretaries are not delegated to provide hygienic care because they do not have formal preparation and legal recognition. The registered nurse performs other activities such as treatment, admissions, and administering intravenous medications. The licensed practical nurse performs activities such as providing oral medications.

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?

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 client is receiving a unit of packed red blood cells (PRBC). The client experiences tingling in the fingers and headache. What is the nurse's priority action?

Stop the transfusion Rationale: Tingling in the fingers and headache may be an indication of an adverse reaction to the transfusion. The nurse's priority action is to stop the infusion and begin a normal saline infusion at KVO (keep vein open). The client should be assessed—including vital signs—then the physician should be notified. The physician should be called after assessment of the patient and implementation of immediate action to stop the transfusion. Slowing the infusion rate is not appropriate if the patient is experiencing a reaction or suspected of having a reaction. Assessment of the IV site is part of the general patient assessment and is not related to a blood transfusion reaction.