Correct Answer: A

Rationale: The correct answer is A: A client who is postoperative following a laminectomy 12 hr ago and is unable to void. This client is the highest priority because postoperative urinary retention can lead to serious complications such as bladder distention, infection, or even renal damage. Immediate intervention is needed to prevent these complications.


Choice B: A client newly diagnosed with pancreatic cancer starting IV chemotherapy is important but not as urgent as the postoperative client with urinary retention.


Choice C: A client with peripheral vascular disease and an absent pedal pulse in the right foot is concerning but does not require immediate intervention compared to the postoperative client.


Choice D: A client with MRSA and a mild fever is important, but urinary retention in the postoperative client takes precedence due to the risk of serious complications.

In summary, the postoperative client with urinary retention requires immediate attention to prevent complications, making them the highest priority.

Correct Answer: C

Rationale: The correct answer is C, determining factors that interfere with the documentation of client education. This is the first step the nurse manager should take because it addresses the root cause of the issue. By identifying barriers to documentation, the manager can then develop targeted strategies to improve the process. Training LPNs (
A) may be beneficial, but without addressing documentation barriers, the effectiveness of the training may be limited. Including documentation in performance evaluation (
B) and offering incentives (
D) are premature actions before understanding the underlying issues.

Correct Answer: A

Rationale: The correct answer is A. A confused and restrained client is at high risk for injury and requires immediate attention to prevent harm. Restraints can lead to complications if not monitored closely.

Choices B, C, and D do not present immediate life-threatening situations.
Choice B, a client with a chest tube post-op, should be monitored closely but does not require immediate evacuation.
Choice C, a client in traction, needs assistance but is not in immediate danger.
Choice D, a client on chemotherapy, can be monitored while ambulatory. In summary, the confused and restrained client requires urgent attention due to the risk of harm, making them the priority for evacuation.

Correct Answer: D

Rationale: The correct answer is D: Clarify competencies with the medical-surgical charge nurse. This is the first action the nurse should take because it directly addresses the immediate concern of lacking experience on the unit. By clarifying competencies with the charge nurse, the nurse can determine which tasks they are competent to perform and seek guidance on those they are not. This ensures patient safety and promotes professional accountability.



Choices A, B, and C do not address the nurse's immediate need to clarify competencies and may delay essential information needed to provide safe care. Referring to the resource nurse or supervisor may not provide the necessary guidance on specific competencies. Requesting orientation may be important but not the first step in addressing the lack of experience.

Correct Answer: B

Rationale: The correct answer is B because tagging a malfunctioning piece of equipment as broken is a task that can be safely delegated to an unlicensed assistive personnel (AP). This task does not require nursing judgment or specialized knowledge. The other choices involve tasks that require nursing assessment, critical thinking, or education, which should not be delegated to APs. Checking on a client with a beeping telemetry monitor (choice
A) involves potential patient safety issues that require immediate nursing intervention. Determining oxygen flow rate accuracy (choice
C) and instructing a client on the use of an incentive spirometer (choice
D) both involve assessing and educating the patient, which are nursing responsibilities.