Question

A nurse leader notices that a staff member frequently asks for help, appears disengaged at times, and is becoming a source of frustration for the team. Morale on the unit is declining, and other nurses have begun speaking negatively about him. Using TeamSTEPPS communication principles, which of the following is the MOST appropriate leadership approach?

Answer 1

Correct Answers:

Use the DESC Script to describe the behavior objectively, express its impact on the team, suggest solutions such as reviewing his workload and building independence, and explain positive consequences; use CUS statements if needed to address concerns about morale and workflow.

Rationale :

💬The TeamSTEPPS DESC Script is a structured, assertive communication tool that enables nurse leaders to address behavioral and teamwork issues respectfully and effectively.

🤝By describing the behavior, expressing its impact, suggesting solutions, and stating consequences, the leader promotes clarity, mutual understanding, and constructive feedback rather than blame.

⚖️This approach supports psychological safety and professional accountability, which are essential for maintaining team morale and effective collaboration.

🚨When morale or workflow is compromised, integrating CUS statements (Concerned, Uncomfortable, Safety issue) helps communicate urgency and ensures that the discussion centers on team well-being and patient safety.

📌Core Message

Using DESC and CUS fosters assertive, respectful communication that resolves conflict, strengthens team cohesion, and promotes safe, effective leadership.

Answer 2

Correct Answers:

Place the patient on a cardiac monitor
Review the patient’s medications to determine if any contain or retain potassium
Notify the healthcare provider (HCP)

Rationale :

⚡A serum potassium of 7.0 mEq/L indicates severe hyperkalemia, a life-threatening condition.

❤️Continuous cardiac monitoring detects dysrhythmias caused by high potassium levels.

💊Reviewing medications prevents further potassium retention (e.g., ACE inhibitors, spironolactone).

📞Notifying the healthcare provider ensures rapid intervention such as calcium gluconate or dialysis to prevent cardiac arrest.

📌Core Message

Hyperkalemia requires immediate cardiac monitoring, medication review, and prompt provider notification to prevent fatal dysrhythmias.

Answer 3

Correct Answers:

Weight gain
Cola-colored urine
Increased BUN

Rationale :

💧Acute glomerulonephritis causes inflammation of the glomeruli, reducing filtration and leading to fluid retention and weight gain.

🩸Cola-colored urine results from hematuria, a classic sign of glomerular damage.

🧪An elevated BUN indicates impaired renal filtration and nitrogenous waste accumulation.

📈These symptoms reflect glomerular injury and decreased renal function due to immune-mediated inflammation.

📌Core Message

Acute glomerulonephritis manifests with weight gain, cola-colored urine, and increased BUN from reduced renal filtration.

Answer 4

Correct Answers:

Assess for mental status changes and place on seizure precautions.

Rationale :

🧠Hyponatremia (Na⁺ 115 mEq/L) causes neurological symptoms due to cerebral edema from fluid shifts.

⚠️Mental status changes such as confusion or lethargy may precede seizures or coma.

🛏️Seizure precautions protect the patient from injury during neurologic disturbances.

💧Rapid correction of sodium is dangerous, so close monitoring is the safest initial intervention.

📌Core Message

Severe hyponatremia requires neuro assessment and seizure precautions due to risk of cerebral edema.

Answer 5

Correct Answers:

Hgb of 9 g/dL and Hct of 28% on a patient who is receiving a second unit of blood

Rationale :

💉Transfusion reactions or bleeding may occur if hemoglobin and hematocrit fail to rise during blood administration.

⚠️This indicates continued loss or hemolysis, requiring immediate reassessment.

🩸Monitoring lab values during transfusion is essential to detect ineffective therapy or complications.

📞Prompt provider notification prevents hypoxia or shock due to inadequate oxygen-carrying capacity.

📌Core Message

Unexpected low Hgb/Hct during transfusion signals possible bleeding or reaction and needs immediate action.

Answer 6

Correct Answers:

Assessment of fluid volume status
Assessing the stoma for perfusion
Assess for skin breakdown around the stoma

Rationale :

💧A new ileostomy increases risk for fluid and electrolyte imbalance due to continuous fluid loss.

👀Assessing stoma perfusion ensures adequate blood flow and tissue viability post-surgery.

🩹Peristomal skin care prevents breakdown from caustic stool enzymes and leakage.

🏥These assessments promote early detection of complications and ensure optimal adaptation to the ostomy.

📌Core Message

Post-ileostomy priorities include fluid monitoring, stoma assessment, and skin protection to prevent complications.

Answer 7

Correct Answers:

Administer IV calcium gluconate, give 25 units of subcutaneous insulin, and 1 amp of D50

Rationale :

⚡Peaked T waves on ECG indicate severe hyperkalemia, posing immediate cardiac risk.

💉IV calcium gluconate stabilizes the myocardial membrane, reducing arrhythmia risk.

🩸Insulin with D50 shifts potassium into cells, rapidly reducing serum levels.

🚨This is a temporary emergency measure until definitive therapy like dialysis can be initiated.

📌Core Message

Emergency hyperkalemia requires calcium gluconate and insulin with D50 to protect the heart and lower potassium quickly.

Answer 8

Correct Answers:

Epinephrine — it is the first-line, life-saving medication that rapidly reverses airway swelling, bronchoconstriction, and circulatory collapse in anaphylaxis.

Rationale :

⚡Epinephrine is the most critical, first-line medication in the management of anaphylaxis because it directly counteracts the physiological effects of severe allergic reactions.

💨It causes bronchodilation by relaxing smooth muscles in the airways, relieving bronchoconstriction and restoring adequate ventilation.

❤️Through vasoconstriction, it reverses hypotension and vascular collapse, stabilizing circulatory function and improving tissue perfusion.

🩺Administering epinephrine promptly prevents progression to respiratory or cardiac arrest, while adjunct medications such as antihistamines and corticosteroids only provide supportive relief after stabilization.

📌Core Message

Epinephrine is the life-saving first-line medication for anaphylaxis, as it swiftly reverses airway obstruction, bronchoconstriction, and circulatory collapse.

Answer 9

Correct Answers:

Adequate blood flow through pulmonary circulation

Rationale :

💔A pulmonary embolism obstructs blood flow to the lungs, disrupting gas exchange.

💁‍♂️This results in ventilation-perfusion mismatch, reducing oxygen delivery to tissues.

📉Impaired perfusion leads to hypoxemia and increased pulmonary pressure.

⚡Prompt recognition prevents cardiac strain and respiratory failure.

📌Core Message

Pulmonary embolism impairs pulmonary blood flow, disrupting gas exchange and oxygenation.

Answer 10

Correct Answers:

25 mcg

Rationale :

💁‍♂️To convert mg to mcg, multiply by 1,000 (0.025 mg × 1,000 = 25 mcg).

⚖️However, for lanoxin (digoxin) dosing, 0.025 mg equals 25 mcg

🩺0.025 mg × 1,000 = 25 mcg, so the correct choice is actually 25 mcg.

⚠️Accuracy in conversions prevents medication errors and ensures safe drug administration.

📌Core Message

0.025 mg equals 25 mcg, emphasizing accurate unit conversion to prevent dose errors.

2 :
A patient with Acute Kidney Injury (AKI) has a serum potassium level of 7.0 mEq/L. You should plan which actions as a priority in caring for this patient? (Select all that apply.)

3 :
A nurse is caring for a patient with acute glomerulonephritis. Which of the following signs and symptoms would the nurse expect to see? (Select all that apply.)

4 :
A patient is admitted with a serum sodium level of 115 mEq/L. What nursing intervention should be administered?

5 :
You are the charge nurse receiving morning laboratory and respiratory data on your clients. Which data requires immediate attention?

6 :
The nurse is caring for a patient with a new ileostomy. What will the nurse’s top priorities for this patient be? (Select all that apply.)

7 :
A nurse is caring for a patient with chronic kidney disease that’s worsened over the past two years. While wearing a telemonitor, the nurse notes the patient presents with peaked T waves. Which of the following actions would be a priority for the nurse to take?

9 :
The patient is being treated for a pulmonary embolism, and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?

10 :
A patient is to receive 0.025 mg lanoxin (Digoxin) PO. How many micrograms is this?

2 : A patient with Acute Kidney Injury (AKI) has a serum potassium level of 7.0 mEq/L. You should plan which actions as a priority in caring for this patient? (Select all that apply.)

3 : A nurse is caring for a patient with acute glomerulonephritis. Which of the following signs and symptoms would the nurse expect to see? (Select all that apply.)

4 : A patient is admitted with a serum sodium level of 115 mEq/L. What nursing intervention should be administered?

5 : You are the charge nurse receiving morning laboratory and respiratory data on your clients. Which data requires immediate attention?

6 : The nurse is caring for a patient with a new ileostomy. What will the nurse’s top priorities for this patient be? (Select all that apply.)

7 : A nurse is caring for a patient with chronic kidney disease that’s worsened over the past two years. While wearing a telemonitor, the nurse notes the patient presents with peaked T waves. Which of the following actions would be a priority for the nurse to take?

9 : The patient is being treated for a pulmonary embolism, and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?

10 : A patient is to receive 0.025 mg lanoxin (Digoxin) PO. How many micrograms is this?

2 :
A patient with Acute Kidney Injury (AKI) has a serum potassium level of 7.0 mEq/L. You should plan which actions as a priority in caring for this patient? (Select all that apply.)

3 :
A nurse is caring for a patient with acute glomerulonephritis. Which of the following signs and symptoms would the nurse expect to see? (Select all that apply.)

4 :
A patient is admitted with a serum sodium level of 115 mEq/L. What nursing intervention should be administered?

5 :
You are the charge nurse receiving morning laboratory and respiratory data on your clients. Which data requires immediate attention?

6 :
The nurse is caring for a patient with a new ileostomy. What will the nurse’s top priorities for this patient be? (Select all that apply.)

7 :
A nurse is caring for a patient with chronic kidney disease that’s worsened over the past two years. While wearing a telemonitor, the nurse notes the patient presents with peaked T waves. Which of the following actions would be a priority for the nurse to take?

9 :
The patient is being treated for a pulmonary embolism, and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?

10 :
A patient is to receive 0.025 mg lanoxin (Digoxin) PO. How many micrograms is this?