A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take first?

Correct Answer: A

Rationale: Post-cholecystectomy pain surgical or gas-related requires the nursing process: assessment first. Assessing the client's pain level (e.g., scale 0-10, location, quality) identifies severity and cause, guiding intervention medication for incision pain, repositioning for shoulder gas pain per ABC priorities (circulation intact, pain affects recovery). Administering medication without assessment risks over- or under-treatment, repositioning may not address root pain, and a heating pad could worsen inflammation if misapplied. Assessment informs a targeted plan, ensuring timely relief, aligning with evidence-based care, and reflecting the nurse's role in addressing postoperative discomfort effectively.

Correct Answer: D

Rationale: Staff preferences rank lowest in care objectives patient needs, via plans, holistic views, and standards, take precedence. In Stephanie's hospital, a nurse's shift preference bows to a patient's urgent need, ensuring care aligns with evidence, not whim. Her leadership reinforces this patient-first ethos, critical in a tertiary setting where standards drive quality, guiding new nurses to prioritize clinical over personal considerations for optimal outcomes.

Correct Answer: B

Rationale: Encouraging near-miss reports like a wrong med caught flags safety risks early, preventing harm, a just culture' pillar. It's not about authority, satisfaction drops, or conflict learning rules. On the committee, you push this to catch issues, aligning with safety where openness saves lives, as in error trends, fostering vigilance and improvement without blame.

Correct Answer: A

Rationale: Effective delegation follows the five rights, including right direction clear, specific instructions. This client needs to ambulate using a walker three times today' provides precise guidance on task, frequency, and method, ensuring the AP understands expectations within their scope, promoting client mobility safely and consistently. Whenever they want' lacks structure, risking over- or under-ambulation, while as you see fit' delegates judgment beyond the AP's role, inviting error. Until they're tired' is vague and unsafe, ignoring clinical goals or limits. The specific direction supports rehabilitation, prevents confusion, and aligns with the nurse's oversight duty, ensuring the AP executes the task correctly while maintaining client safety and care plan adherence.

Correct Answer: C

Rationale: In alcohol withdrawal with confusion, weakness, and tremors, the nurse expects thiamin deficiency, not calcium, iron, or B12. Chronic alcohol use depletes thiamin (vitamin B1), risking Wernicke's encephalopathy neurological symptoms match this. Calcium might cause spasms, iron anemia, and B12 neuropathy, but thiamin fits withdrawal's acute presentation. Leadership anticipates this imagine a disoriented patient; thiamin IV prevents progression, safeguarding brain function. This reflects nursing's grasp of nutritional deficits, ensuring rapid, targeted care in addiction emergencies effectively.

Correct Answer: C

Rationale: Management suggests efficiency , not dynamism, risk, or creativity. Managers like scheduling nurses focus on order, contrasting with leadership's flair. In healthcare, this ensures smooth operations, aligning management with stability and resource use.

Correct Answer: A

Rationale: Cyclical staffing is oldest, unlike FTE, decentralized, or missing. Nurse managers roster this like rotating shifts contrasting with modern FTE. It's foundational in healthcare, aligning leadership with traditional scheduling.

Correct Answer: C

Rationale: Internal factors are stress types, unlike mantra, chores, or missing. Nurse leaders like emotional strain address this, contrasting with externals. In healthcare, it's internal focus, aligning leadership with psyche (D assumed missing).

Correct Answer: D

Rationale: Leadership links to change not consistency, planning, or paperwork. Nurse leaders like new protocols drive this, contrasting with routine. In healthcare, it's progress, aligning leadership with vision.