Nokea
The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should include which interventions as examples of the nurse acting as a client advocate? Select all that apply.
- A. Obtaining an informed consent for a surgical procedure
- B. Providing information necessary for a client to make informed decisions
- C. Providing assistance in asserting the client's human and legal rights if the need arises
- D. Including the client's religious or cultural beliefs when assisting the client in making an informed decision
- E. Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being
Correct Answer: B,C,D,E
Rationale: In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. The nurse advocates for the client by providing information needed so that the client can make an informed decision. The nurse needs to consider the client's religion and culture when functioning as an advocate and when providing care. The nurse would include the client's religious or cultural beliefs in discussions about treatment plans so that an informed decision can be made. The nurse also defends clients' rights in a general by speaking out against policies or actions that might endanger the client's well-being or conflict with his or her rights. Informed consent is part of the primary health care provider-client relationship; in most situations, obtaining the client's informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent.
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The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
- A. Administer a PRN antianxiety medication immediately.
- B. Provide isolation for the client in the unit's 'time-out' room.
- C. Observe the client in an ongoing manner but do not intervene.
- D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D
Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.
The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?
- A. Isolate the child until the skin vesicles have dried and crusted.
- B. Ensure that the child uses a separate bathroom for elimination.
- C. Bring all household members to the clinic for a varicella vaccine.
- D. Request a prescription for antibiotics for all household members.
Correct Answer: A
Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.
A client asks the nurse how to become an organ donor. Which information should the nurse include in the discussion?
- A. The client can donate by written consent.
- B. A family member must witness the consent.
- C. The donor must be older than 21 years of age.
- D. A family member must be present when a client consents to organ donation.
Correct Answer: A
Rationale: The client has the right to donate her or his own organs for transplantation, and any person who is 18 years of age or older may become an organ donor by written consent without the permission or presence of the family. In the absence of suitable documentation, a family member or legal guardian can authorize donation of the decedent's organs.
The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.
The nurse is working in the emergency department of a small local hospital when a client with multiple stab wounds arrives by ambulance. Which action by the nurse is contraindicated when handling potential legal evidence?
- A. Initiating a chain of custody log.
- B. Giving clothing and wallet to the family.
- C. Cutting clothing along seams, avoiding stab holes.
- D. Placing personal belongings in a labeled, sealed paper bag.
Correct Answer: B
Rationale: Potential evidence is never released to the family to take home. Basic rules for handling evidence include initiating a chain of custody log to track handling and movement of evidence, limiting the number of people with access to the evidence, and carefully removing clothing and placing personal belongings in a labeled, sealed paper bag to avoid destroying evidence. This also usually includes cutting clothes along seams, while avoiding areas where there are obvious holes or tears.