Nokea
A hospitalized client wants to leave the hospital before being discharged by the primary health care provider (PHCP). Which action should be the next intervention for the nurse to implement?
- A. Notify the nursing supervisor of the client's plans to leave.
- B. Ask the client about transportation plans from the hospital.
- C. Arrange medication prescriptions at the client's preferred pharmacy.
- D. Discuss the potential consequences of the plans for leaving with the client.
Correct Answer: A
Rationale: The nurse notifies the nursing supervisor of the client's plan to leave without the primary PHCP's approval to ensure client safety and to help the nurse manage the situation. This will help the nurse manage the situation in a thoughtful, comprehensive manner and complete nursing interventions that include asking about transportation, arranging medication prescriptions, and discussing the risks and benefits of leaving or remaining in the hospital. The PHCP should be contacted and the client encouraged to remain until the PHCP arrives. The nurse avoids coercion, restraint, or security measures meant to prohibit the client's exit to prevent claims of false imprisonment.
You may also like to solve these questions
The nurse is teaching a client with a diagnosis of cardiomyopathy about home care safety measures. Which instruction is most important for the nurse to include?
- A. Reporting pain
- B. Appropriate vasodilator administration
- C. Avoiding over-the-counter medications
- D. Moving slowly from a sitting to a standing position
Correct Answer: D
Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Reporting pain, while important, is not directly related to the issue of safety. Vasodilators are not normally prescribed for the client with cardiomyopathy. Option 3, although important, is not directly related to the issue of safety.
The nurse is caring for the body and personal belongings of a client who died as a result of multiple gunshot wounds. Which actions should the nurse take to properly secure and handle legal evidence? Select all that apply.
- A. Place paper bags on the hands and feet.
- B. Give the clothing and wallet to the family.
- C. Cut clothing along the seams, avoiding bullet holes.
- D. Collect all personal items, including items from clothing pockets.
- E. Place wet clothing and personal belongings in a labeled, sealed plastic bag.
- F. Do not allow family members, significant others, or friends to be alone with the client.
Correct Answer: A,C,D,F
Rationale: Basic rules for securing and handling evidence include minimally handling the body of a deceased person; placing paper bags on the hands and feet and possibly over the head of a deceased person (protects trace evidence and residue); placing clothing and personal items in paper bags (plastic bags can destroy items because items can sweat in plastic); cutting clothes along seams, avoiding areas where there are obvious holes or tears; and collecting all personal items, including items from clothing pockets. Evidence is never released to the family to take home, and family members, significant others, or friends are not allowed to be alone with the client because of the possibility of kindizing any existing legal evidence.
The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity should the nurse plan time for after the arterial blood is drawn?
- A. Holding a warm compress over the puncture site for 5 minutes
- B. Encouraging the client to open and close the hand rapidly for 2 minutes
- C. Applying pressure to the puncture site by applying a 2 x 2 gauze for 5 minutes
- D. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
Correct Answer: C
Rationale: Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.
The nurse is assisting with the transfer of a client from the operating room table to a stretcher. Which interventions should the nurse implement to ensure client safety? Select all that apply.
- A. Check the client's level of consciousness.
- B. Check wheel locks of the operating room table.
- C. Complete the client transfer as quickly as possible.
- D. Tell the client to move self from the table to the stretcher.
- E. Raise side rails after the client is positioned on the stretcher per agency policy.
Correct Answer: A,B,E
Rationale: As part of the safe transfer of a client after a surgical procedure, the nurse should assess the client's level of consciousness and, if appropriate, let the client know that she or he will be transferred from the operating room table to the stretcher. The nurse checks the wheel locks of the table and the stretcher to prevent any movement during the transfer. In addition, the nurse raises the side rails per agency policy to prevent the client from falling off the stretcher. This is important because the client is likely to be sedated or disoriented and unable to protect herself or himself from falling. Personnel avoid hurried movements and rapid changes in position because hurried movements predispose the client to hypotension; moreover, secure, deliberate movement increases the security of the client. Because the client remains affected by anesthesia, the client should not move herself or himself.
Upon transfer from the post-anesthesia care unit (PACU) after spinal fusion, which technique should the nurse use to transfer the client from the stretcher to the bed?
- A. A bath blanket and the assistance of four people
- B. A bath blanket and the assistance of three people
- C. A transfer board and the assistance of two people
- D. A transfer board and the assistance of four people
Correct Answer: D
Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer board and the assistance of four people. This permits optimal stabilization and support of the spine, while allowing the client to be moved smoothly and gently. Therefore, the remaining options are incorrect and unsafe.