Nokea
A charge nurse is planning care for a unit with limited staffing due to a flu outbreak. Which of the following actions should the charge nurse prioritize?
- A. Assign assistive personnel to provide client education on hand hygiene.
- B. Ensure all clients receive their scheduled baths on time.
- C. Reassess clients with unstable vital signs every 2 hours.
- D. Delegate documentation of intake and output to the unit clerk.
Correct Answer: C
Rationale: The correct answer is C: Reassess clients with unstable vital signs every 2 hours. This is the priority because clients with unstable vital signs require frequent monitoring to detect any deterioration or changes in their condition promptly. This action directly impacts patient safety and allows for timely intervention if needed.
Assigning assistive personnel for client education (A) is important for infection control but may not be the priority during a staffing shortage. Ensuring scheduled baths (B) is important for hygiene but can be delayed if necessary. Delegating documentation of intake and output (D) to the unit clerk is not appropriate as it involves clinical judgment and assessment.
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A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
- A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
- B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
- C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
- D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
Correct Answer: C
Rationale: The correct answer is C because administering medication without the client's knowledge and against their refusal constitutes a breach of the duty of care and violates the client's autonomy and right to make decisions about their own treatment. This is an example of negligence as it goes against the ethical principle of informed consent. Choices A, B, and D do not meet the criteria for negligence as they involve actions taken in the best interest of the client, such as preventing harm or reporting concerning findings to the provider. In choice A, the nurse is trying to prevent harm by applying restraints to a client who is making a potentially harmful decision. In choice B, the nurse is identifying and reporting a concerning clinical finding promptly. In choice D, the nurse is attempting to educate the client and prevent harm related to dietary restrictions.
A nurse is caring for a client who is postoperative and reports a pain level of 8 on a scale of 0 to 10. Which of the following actions should the nurse take first?
- A. Administer the prescribed analgesic.
- B. Notify the provider of the pain level.
- C. Reposition the client for comfort.
- D. Document the pain level in the medical record.
Correct Answer: A
Rationale: The correct answer is A: Administer the prescribed analgesic first. Managing pain is a priority to ensure the client's comfort and prevent complications. Administering the analgesic promptly is essential to relieve the client's pain and improve their overall well-being. Notifying the provider (B) can be done after addressing the immediate need for pain relief. Repositioning the client (C) may provide some comfort but should come after administering pain medication. Documenting the pain level (D) is important, but addressing the pain itself takes precedence.
A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?
- A. I am sure these feelings will pass once you go home.
- B. Tell me what you understand about your illness.
- C. Tell me why you feel hopeless.
- D. If I were you, I would ask for a referral to hospice care.
Correct Answer: B
Rationale: The correct answer is B: "Tell me what you understand about your illness." This response shows active listening and encourages the client to express their thoughts and feelings, fostering trust and understanding. It allows the nurse to assess the client's knowledge and perception, helping tailor support accordingly. Choice A dismisses the client's feelings, lacking empathy. Choice C may come off as confrontational, potentially shutting down communication. Choice D imposes the nurse's opinion on the client. Choices E, F, and G are not applicable. In summary, choice B promotes therapeutic communication and client-centered care, while the other choices may hinder the nurse-client relationship.
A nurse manager is reviewing the unit's compliance with infection control protocols. Which of the following findings requires immediate intervention?
- A. An assistive personnel wears gloves while feeding a client.
- B. A nurse uses hand sanitizer before entering a client's room.
- C. A nurse reuses a disposable gown after leaving a client's room.
- D. A client's visitor washes their hands upon entering the room.
Correct Answer: C
Rationale: Reusing a disposable gown violates infection control protocols, as it risks cross-contamination. The other actions align with or exceed standard infection control practices.
A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?
- A. Withholding a dose of narcotic pain medication when the client has respiratory depression
- B. Discussing advance directives with the client and the client's family
- C. Providing comfort care measures to the client
- D. Allowing the client's family unlimited visitation at the time of death
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm. In this scenario, withholding a dose of narcotic pain medication when the client has respiratory depression aligns with this principle as administering the medication could further compromise the client's respiratory status and potentially harm them. By withholding the medication, the nurse is prioritizing the client's safety and well-being.
Summary of Incorrect Choices:
B: Discussing advance directives is important but does not directly relate to nonmaleficence in this context.
C: Providing comfort care measures is essential but does not specifically demonstrate the principle of nonmaleficence.
D: Allowing unlimited visitation may support emotional well-being but does not directly address the principle of nonmaleficence.