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A client complains every morning that the night shift nursing staff does not answer his call light promptly to assist his elimination needs. His concerns are not shared with the Nurse Manager, and he falls while trying to walk to the bathroom. This fall could be attributed to which of the following?
- A. Breakdown in communication
- B. Lack of staff
- C. Lack of concern
- D. Breakdown in management
Correct Answer: A
Rationale: The correct answer is A: Breakdown in communication. The client's complaint about the night shift nursing staff not responding promptly to his call light indicates a lack of effective communication between the client and the staff. This breakdown in communication leads to the client attempting to walk to the bathroom alone, resulting in a fall. Lack of staff (B) or lack of concern (C) are not directly related to the client's fall, as the core issue lies in communication. Breakdown in management (D) could contribute to communication issues, but the immediate cause of the fall is the lack of communication between the client and the nursing staff.
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Strategies to advance your career and opportunities available in your first job can coexist. Identify factors that will help you prioritize these opportunities to fulfill your goals. (Select all that apply.)
- A. Self-actualization and assessing your values and your lifestyle.
- B. Determine where you can grow and develop professionally.
- C. Your ability to work as a team member.
- D. Reflect on your long-term career aspirations.
Correct Answer: A
Rationale: The correct answer is A because self-actualization and assessing your values and lifestyle are essential for aligning your career goals with personal values, leading to long-term satisfaction and fulfillment. By understanding your core values and lifestyle preferences, you can prioritize job opportunities that align with your aspirations.
Choice B is incorrect because while professional growth is important, it may not necessarily align with your personal values and lifestyle. Choice C is incorrect as teamwork skills are important, but they do not directly relate to prioritizing career opportunities based on personal values. Choice D is incorrect as reflecting on long-term career aspirations alone may not provide a holistic view of how to prioritize opportunities in alignment with personal values and lifestyle.
A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent
feedings through an open system. Which of the following actions should the nurse take first?
- A. Make sure the enteral formula is at room temperature.
- B. Wipe the top of the formula can with alcohol.
- C. Rinse the feeding bag with water between feedings.
- D. Tell the client to keep the head of the bed elevated at least 30°
Correct Answer: B
Rationale: The correct answer is B: Wipe the top of the formula can with alcohol. This is the first action the nurse should take because it ensures the cleanliness and sterility of the formula before administering it to the client through the NG tube, reducing the risk of contamination and infection.
A: Making sure the enteral formula is at room temperature is important but not the first action to take.
C: Rinsing the feeding bag with water between feedings is not necessary for every feeding and does not address the immediate need to ensure the cleanliness of the formula.
D: Instructing the client to keep the head of the bed elevated is important for preventing aspiration but is not the first action to take in this scenario.
An RN is writing reminders for good documentation for the nurses on her staff. The purpose is to ensure nursing documentation is legally credible. Which of the following is a recommendation she should include in the reminders?
- A. Use shortcuts in documentation.
- B. Only use approved abbreviations.
- C. Documentation should be subjective.
- D. Document after care is provided.
Correct Answer: B
Rationale: The correct answer is B: Only use approved abbreviations. Using approved abbreviations helps prevent misinterpretation and errors in documentation, ensuring legal credibility. Shortcuts in documentation (A) can lead to incomplete or inaccurate information. Subjective documentation (C) may lack objectivity and legal validity. Documenting after care is provided (D) may result in memory bias and inaccuracies. Therefore, emphasizing the use of approved abbreviations is crucial for ensuring accurate, clear, and legally credible nursing documentation.
What is the term used for assigning a rating based on an overall impression?
- A. Recency error.
- B. Leniency error.
- C. Absolute judgment.
- D. Halo error.
Correct Answer: D
Rationale: The correct answer is D: Halo error. Halo error is the term used for assigning a rating based on an overall impression, where one positive attribute influences the overall perception of an individual or object. This can lead to biased evaluations. Recency error (A) is when recent events have a disproportionate impact on the evaluation. Leniency error (B) is when the rater consistently rates all items positively. Absolute judgment (C) is when each item is evaluated independently without considering the overall impression.
An RN comes upon a serious motor vehicle accident that has just occurred and no first responders are on the scene. One car has been flipped upside down, and she can see the driver still in the car. The RN decides to stop and help. She knows she is protected from civil liability as long as she does which of the following?
- A. Acts in an ordinary, reasonable, and prudent professional manner
- B. Assures that information obtained is not communicated to anyone else
- C. Does not make any verbal comments that could lead to economic harm
- D. Fails to meet the established standards of practice
Correct Answer: A
Rationale: The correct answer is A: Acts in an ordinary, reasonable, and prudent professional manner. The RN is protected from civil liability under the Good Samaritan laws when they act in a manner that is considered ordinary, reasonable, and prudent for a healthcare professional in an emergency situation. By stopping to help at the accident scene, the RN is fulfilling their duty to provide aid as a healthcare professional. Choices B and C are incorrect because withholding information or refraining from making certain verbal comments would not protect the RN from liability in this emergency scenario. Choice D is incorrect because failing to meet the established standards of practice would expose the RN to potential liability.