Choice A rationale: While Magnet status can enhance a hospital's reputation and attract patients, the primary purpose of seeking Magnet status is to acknowledge and validate the quality of nursing care, rather than primarily serving as a marketing tool.

Choice B rationale: While Magnet status may contribute to attracting highly qualified nursing staff, the primary focus is on recognizing and promoting excellence in patient care, not specifically on the recruitment of nurses with a particular educational background.

Choice C rationale: Magnet status is not primarily focused on the breadth of services a facility provides. Instead, it is centered on the quality and excellence of nursing care.

The designation does not necessarily indicate the quantity or variety of services offered by a healthcare facility.

Choice D rationale: Magnet status is a designation granted by the American Nurses Credentialing Center (ANCC) to healthcare organizations that demonstrate excellence in nursing practice and outstanding patient care. It signifies that the facility has met rigorous standards for nursing quality, professionalism, and overall commitment to delivering exceptional care to patients.

Choice A rationale: Assigning the orientee to work with an experienced nurse who is a long-time, efficient employee can help the orientee improve her skills and confidence.

Choice B rationale: Waiting until the end of the second week may lead to further issues and does not actively address the current challenges the orientee is facing.

Choice C rationale: Informing the supervisor without directly addressing the nurse may not be the most supportive or proactive approach.

Choice D rationale: Talking to the orientee about working in a less stressful environment may not be the most proactive step at this point. Providing support and guidance within the current work environment is a more immediate solution.

Choice A rationale: The assessment is the client's signed power of attorney and a home medication list, which are important documents that indicate the client's wishes and potential drug interactions. While the client's healthcare power of attorney is important information, the reason for admission should be provided first to give context to the situation.

Choice B rationale: The nurse should start by presenting the immediate situation or concern, which is the client's increasing confusion which needs immediate attention. Choice C rationale: The recommendation is the nurse's suggestion for further diagnostic tests, interventions, or referrals based on the situation, background, and assessment. The currently prescribed medications are relevant, but the primary reason for admission should be communicated first to establish the context of the client's condition. Choice D rationale: The background is the fall at home as the reason for admission, which explains the possible cause of the confusion and the loss of consciousness. This comes after the situation which is the increasing confusion.

Choice A rationale: Reminding the client about new treatments does not address the refusal to write do-not-resuscitate instructions and may not be the most appropriate action.

Choice B rationale: While facilitating a palliative care meeting is important for addressing end-of-life care, it doesn't directly address the provider's refusal to write do not-resuscitate instructions.

Choice C rationale: Providing the healthcare provider with a copy of the client's bill of rights may not be the most effective action in this situation.

Choice D rationale: Initiating a review of the situation by the hospital's ethics committee is appropriate when there is a disagreement between the client's wishes and the healthcare provider's refusal. The ethics committee can help navigate and resolve ethical concerns.

Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.

Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.

Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.

Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.

Choice A rationale: The initial administration of the opioid analgesic is appropriate as long as the nurse adheres to the prescription made.

Choice B rationale: Administering naloxone via IV is an appropriate intervention to reverse the effects of opioid toxicity. It is not the focus of counseling in this scenario.

Choice C rationale: The nurse should have notified the healthcare provider as soon as the client's respiratory rate decreased to 6 breaths/minute, which is a sign of respiratory depression caused by the opioid analgesic. The nurse should not have waited until the client's respiratory rate decreased to 4 breaths/minute, which is a life-threatening condition that requires immediate intervention.

Choice D rationale: Documentation of the client's respiratory rate is essential for monitoring, and there is no indication that the documentation was inappropriate.

Choice A rationale: Vital signs within the normal range two hours after receiving morphine do not indicate an immediate need for intervention by a registered nurse. Choice B rationale: A client reporting severe pain one hour after receiving hydromorphone requires assessment and intervention by a registered nurse to determine the cause of the pain and implement appropriate measures. Hydromorphone is a potent opioid analgesic that can cause serious side effects such as respiratory depression, sedation, hypotension, and constipation. A registered nurse has the knowledge and skills to monitor these effects and intervene if necessary.

Choice C rationale: Changing a fentanyl transdermal patch is a routine procedure and can be safely performed by a practical nurse.

Choice D rationale: A postoperative client reporting incisional pain requires assessment, but the pain level alone does not indica

Choice A rationale: Recording the client's pulse volume distal to the IV site is a nursing responsibility as it involves an assessment of circulation.

Choice B rationale: Reapplying cold compresses is a task that UAP can perform to help minimize swelling and discomfort at the extravasation site.

Choice C rationale: Disposing of the IV tubing after the infusion is discontinued is a nursing responsibility to ensure proper disposal and prevent contamination.

Choice D rationale: Teaching the client about the need to keep the extremity elevated involves patient education and is within the scope of nursing practice.

Choice A rationale: This option ensures that each team member is assigned a task within their scope of practice. The RN can provide assistance with the thoracentesis, and the PN can manage the admission process and client transportation. The UAP can prepare the room, contributing to efficient care delivery.

Choice B rationale: This choice ensures that the RN, who has the highest level of education and scope of practice, is available to assist with the invasive procedure that requires sterile technique and close monitoring. The PN, who can perform basic nursing skills and collect data, can obtain report from the ED nurse and transport the client safely. The UAP, who can perform routine tasks and assist with activities of daily living, can prepare the room for the new admission

Choice C rationale: Assigning the UAP to assist with the thoracentesis might not be appropriate, as this task involves skilled nursing care.

Choice D rationale: Assigning the PN to obtain report and transport the client while the RN obtains report from the ED is not the most efficient use of resources. The RN can manage the admission process, and the PN can assist with the thoracentesis.

Choice A rationale: Paging a chaplain on call can be a supportive measure, but it might not address the immediate need for communication and coordination with the family.

Choice B rationale: Allowing each family member to ask a question one at a time may not be the most effective approach when dealing with multiple and repetitive questions.

Choice C rationale: Requesting the healthcare provider to speak with the family might be appropriate, but it could take time, and the immediate need is to establish effective communication.

Choice D rationale: Asking the family to identify a specific spokesperson helps streamline communication and ensures that information is conveyed more efficiently. This approach can help manage the situation and address the family's concerns collectively.

Choice A rationale: The immediate priority during a fire alarm is to ensure the safety of clients and staff. Instructing everyone to stay in the client rooms with doors closed helps contain any potential smoke or fire, providing protection while the situation is assessed.
Choice B rationale: Instructing family members to stay in the waiting area might not be the primary concern during a fire alarm. The focus is on the safety of clients and staff.
Choice C rationale: While determining the nature of the emergency is important, taking immediate actions to ensure safety is the priority. The charge nurse can address the cause once the safety of individuals is secured.
Choice D rationale: Evacuating clients should only be considered if it is determined to be safe to do so. It's crucial to assess the situation and follow established protocols before initiating evacuation.

Choice A rationale: Consulting with the registered dietitian involves clinical judgment and collaboration with another healthcare professional, which is not within the scope of practice for the UAP.

Choice B rationale: Maintaining a clean and pleasant environment during meals is a task that can be delegated to the UAP to enhance the client's dining experience. Choice C rationale: Setting up the food and drink containers within easy reach is a task that the UAP can perform to facilitate the client's access to meals.

Choice D rationale: Offering specific dietary recommendations, such as high-caloric foods, requires knowledge of nutritional needs, which is beyond the UAP's scope. Choice E rationale: Assisting the client with eating small frequent high-calorie meals is a task that can be delegated to the UAP to support the client's nutritional intake.

Choice A rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice B rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice C rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice D rationale: This could indicate impaired circulation or nerve compression, which could lead to permanent damage or loss of limb if not treated promptly.

Choice A rationale: Placing an isolation cart outside the room is important, because mumps is a contagious viral infection that can be transmitted by respiratory droplets from coughing or sneezing. This intervention prevents the spread of infection and protects other clients and staff from exposure.

Choice B rationale: Instructing the child's parents about the need for transmission precautions is essential for preventing the spread of mumps to other individuals but the most important intervention is to place an isolation cart outside the room. Choice C rationale: Scheduling bedside playtime with the occupational therapist may be beneficial for the child but is not the most critical intervention in preventing transmission.

Choice D rationale: Assigning the child to a room close to the nurse's station may facilitate monitoring but does not directly address the prevention of transmission.

Choice A rationale: The nurse does not need to determine who is assigned the care of the client, as this is not relevant to the immediate situation.

Choice B rationale: The nurse should not enter the room and quietly observe the interaction, as this would delay the intervention and put the client and the visitor at risk.

Choice C rationale: The nurse should not notify the hospital security department immediately, as this would also delay the intervention and may escalate the situation.

Choice D rationale: The nurse should prioritize the safety of the client and the visitor, and intervene to stop the potential violence. The nurse should instruct the visitor to leave the room immediately, and then assess the client's condition and provide appropriate care.

Choice A rationale: Applying portable oxygen for transport to radiology is not the first priority. The immediate concern is assessing and addressing the client's respiratory distress before initiating specific interventions.

Choice B rationale: Administering a nebulizer breathing treatment may be part of the overall plan, but evaluating the breathing pattern is the initial step to determine the severity of respiratory distress.

Choice C rationale: Evaluating the breathing pattern is the priority to assess the client's respiratory status. This information is essential for making informed decisions about immediate interventions, including the administration of oxygen or nebulizer treatments.

Choice D rationale: Starting the prescribed antibiotic is not the first priority. Respiratory assessment takes precedence to address the client's immediate distress.

Choice A rationale: Conducting a closer examination of staff nurses' distribution of pain medication is the first step to identify any issues or patterns contributing to the higher than-usual administration of narcotic pain medications.

Choice B rationale: Holding a mandatory staff meeting may be necessary, but a focused examination should precede broader discussions.

Choice C rationale: Questioning clients about the effectiveness of pain medication is an important aspect of the investigation but should follow a thorough examination of medication distribution.

Choice D rationale: Discussing with the healthcare provider about changing client analgesia may be considered later based on the findings of the examination.

Choice A rationale: It's crucial to address the client's concerns and clarify any misunderstandings about the cardiac catheterization procedure. Re-education and providing additional information can help alleviate anxiety and ensure the client has a clear understanding of the procedure, including the role of wires used during the catheterization.

Choice B rationale: Postponing the procedure may not be necessary if the client's concerns can be adequately addressed through communication and education. Choice C rationale: Calling the client's next of kin for verbal consent is not appropriate in this situation, as the client is capable of providing informed consent once concerns are addressed.

Choice D rationale: Notifying the healthcare provider may be necessary if there are persistent issues or if the client decides to decline the procedure after further clarification.

Choice A rationale: While a history of vomiting at home for 3 days prior to surgery may be relevant, the information provided by the PACU nurse already includes the time of the last administration of nausea medications, making this option less critical at this moment.

Choice B rationale: Providing information about the abdomen, bowel sounds, and the absence of bleeding on the dressing is essential for assessing the postoperative condition of the client. It gives the receiving nurse a comprehensive overview of the client's immediate status following surgery.

Choice C rationale: Refusal to take ice chips for complaints of dry mouth is relevant to the client's comfort and hydration but may not be as critical as assessing surgical outcomes and complications.

Choice D rationale: Information about peripheral pulses and the range of motion of both legs is important but may be more pertinent to the neurological and circulatory assessment rather than immediate postoperative concerns. The surgical site and abdominal assessment are more directly related to the recent laparotomy.

Choice A rationale: Verifying with the client that the blood was drawn is a good practice, but it might not provide immediate information about the current glucose level. The nurse needs a timely assessment to determine whether the client can safely receive the scheduled breakfast.

Choice B rationale: Checking when insulin was last administered is important, but it doesn't provide real-time information about the current glucose level. The nurse needs this information before deciding on breakfast administration.

Choice C rationale: Performing a capillary glucose test is a quick way to obtain current blood glucose levels, allowing the nurse to make an informed decision about administering the breakfast tray. This action is consistent with assessing the client's immediate status.

Choice D rationale: Giving the client the breakfast tray without knowing the current glucose level could be unsafe and against the prescribed plan of care. Assessing the glucose level is a necessary step before administering meals, especially in clients with diabetes.

Choice A rationale: Directing the UAP to delay weighing the client might not address the underlying issue. Understanding the client's refusal is essential for appropriate interventions.

Choice B rationale: Documenting that the client refused daily weights is important for documentation purposes, but it doesn't address the issue or provide information on the client's fluid status.

Choice C rationale: Instructing the UAP to weigh the client using a bed scale is a good option, but understanding the client's concerns or reasons for refusal is important for effective communication and addressing potential issues.

Choice D rationale: Asking the client why he does not want to be weighed is essential for understanding and addressing the client's concerns. It allows the nurse to provide education, reassurance, or alternative solutions to ensure the client's cooperation with the prescribed care plan.

Choice A rationale: Sexual activity should be avoided until the client and all sexual partners have completed treatment and are symptom-free. This is to prevent reinfection and transmission of the STI.

Choice B rationale: Persons with STIs are not reported to local health departments unless they have a reportable disease such as syphilis, gonorrhea, chlamydia or HIV. Trichomoniasis is not a reportable disease in most jurisdictions.

Choice C rationale: Most contraceptives do not protect against infection. The only contraceptive method that provides some protection against STIs is the male or female condom.

Choice D rationale: The nurse should remain non-judgmental and assure the client of confidentiality. This is because the nurse has a professional and ethical obligation to respect the client's autonomy, privacy and dignity.

Choice A rationale: In the context of influenza, especially during flu seasons, wearing a fitted respirator mask is recommended for healthcare personnel to prevent the spread of respiratory droplets.

Choice B rationale: Instructing the UAP to notify the nurse of respiratory status changes is important but doesn't address the immediate need for proper respiratory protection.

Choice C rationale: Assigning the UAP to another client is not necessary if proper precautions are followed. The focus should be on correcting the current situation.

Choice D rationale: Reviewing the need for the UAP to wear a face mask is insufficient; a fitted respirator mask is more appropriate for respiratory illnesses like influenza.

Choice A rationale: This is because ceftriaxone is an antibiotic that can be administered by gravity drip without an IV pump, as long as the flow rate is monitored and adjusted manually.

Choice B rationale: Heparin in normal saline, especially for deep vein thrombosis, requires precise control of the infusion rate, making an infusion pump necessary.

Choice C rationale: Regular insulin in normal saline for ketoacidosis should be administered via an IV pump due to the need for precise control of the infusion rate.

Choice D rationale: Magnesium in normal saline for hypomagnesemia may also require careful control of the infusion rate, making an infusion pump preferable.

Choice A rationale: The nurse can delegate urinary catheter irrigations to the PN, as this is a skill that can be performed by a licensed nurse under the supervision of a registered nurse (RN).

Choice B rationale: Initiating teaching for client care after discharge is within the scope of a registered nurse and may not be delegated to a practical nurse.

Choice C rationale: Beginning initial sterile wound care for surgical clients may fall under the scope of a registered nurse or other licensed staff, not necessarily a practical nurse.

Choice D rationale: Receiving a postoperative client and conducting the assessment also requires the RN's critical thinking and clinical skills.