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A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?
- A. Ask the nursing assistant to complete an incident report
- B. Check the client's level of consciousness and vital signs
- C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
- D. Ask the nursing assistant to assist in getting the client back to bed
Correct Answer: B
Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.
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While documenting on a paper form, the nurse realizes they have made a mistake writing the progress note. What should the nurse do?
- A. Use a black marker to fully cover up the mistake.
- B. Do not make any changes to the progress note but explain later in the note that a mistake was made and note what should have been written.
- C. Use whiteout to cover over the mistake and write over it.
- D. Inform the client about the mistake and offer to provide a corrected copy.
Correct Answer: B
Rationale: In the scenario described, it is essential for the nurse not to alter the original progress note. Option B is the correct course of action as it maintains the integrity of the documentation while acknowledging the error for transparency and accuracy. Using a black marker (Option A) or whiteout (Option C) can be seen as an attempt to conceal the mistake, which is not in line with professional standards. Option D is incorrect because the mistake should be addressed within the documentation itself, not by informing the client directly about it.
During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?
- A. Ask the television crew to interview the individuals attending the program individually.
- B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
- C. Explain to the television crew that videotaping is not allowed.
- D. Allow the television crew to videotape the program.
Correct Answer: C
Rationale: Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.
What is a true statement about post-discharge follow-up?
- A. The nurse should ensure the client is educated on their discharge instructions.
- B. If the client seems stable, they likely do not need a follow-up visit.
- C. The physician is responsible for ensuring the client has their prescriptions upon discharge.
- D. If the client has questions, the nurse should address them before discharge.
Correct Answer: A
Rationale: The correct statement is that the nurse should ensure the client is educated on their discharge instructions. This is crucial to promote continuity of care and prevent adverse events. The responsibility of educating the client falls on the nurse, not assuming stability without a follow-up visit. While the physician may prescribe medications, it is the nurse's responsibility to ensure the client has them before discharge. Instructing the client to bring up questions at a follow-up appointment is not ideal; all questions should be addressed before discharge to ensure the client's understanding and compliance.
When preparing a client for a neck x-ray, what is the most appropriate action for the nurse to take if the client expresses concern about removing a religious medal worn around the neck?
- A. Telling the client that the medal and chain will be kept at the nurse's station for safekeeping while the client is undergoing the x-ray
- B. Asking the client to remove the medal until the x-ray has been completed
- C. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms
- D. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department
Correct Answer: C
Rationale: When a client undergoing a neck x-ray expresses concern about removing a religious medal worn around the neck, the nurse should assist the client in pinning the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. This action allows the client to keep the medal close without interfering with the x-ray procedure. It is important to ensure that the radiology department staff is informed about this arrangement. Asking the client to remove the medal, keeping it at the nurse's station, or placing it in the bedside stand is not appropriate. These actions may lead to the loss of the medal and chain and do not address the client's concerns about the religious significance of the item.
The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?
- A. Checking the crash cart to ensure that all needed supplies are readily available in case of an emergency
- B. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift
- C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed
- D. Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay
Correct Answer: D
Rationale: Quality improvement, also known as performance improvement, focuses on processes contributing to client safety and care outcomes. Retrospective audits involve reviewing medical records after discharge for compliance with standards. Concurrent audits assess staff compliance during a client's stay. Therefore, obtaining the medical record from the hospital's record room for review is crucial in a retrospective audit. Options A, B, and C are more suited for concurrent audits as they involve real-time assessment during a client's stay.