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A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
- A. Apply vest restraints to residents who are confused
- B. Keep all four side rails up on beds at night
- C. Accompany residents over 85 years of age during ambulation
- D. Implement rounds every 2 hours during the day to offer toileting
Correct Answer: D
Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.
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A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following should the nurse take first?
- A. Refer the AP to the facility procedure manual
- B. Demonstrate the proper client transfer technique for the AP
- C. Instruct the AP to request assistance when unsure about a task
- D. Help the AP assist the client with the transfer
Correct Answer: D
Rationale: The correct first action for the nurse is to ensure the safety of the client by immediately intervening to help the AP with the transfer. This hands-on assistance can prevent any potential harm to the client. Referring the AP to the facility procedure manual (Choice A) might take time and delay the necessary immediate action. Demonstrating the proper technique (Choice B) can be done after ensuring the client's safety. Instructing the AP to request assistance (Choice C) is not the most urgent step when a client's safety is at risk.
What is an episiotomy?
- A. A surgical incision of the perineum to prevent tearing during delivery.
- B. Releasing the red plug from the cervix just before crowning occurs.
- C. An incision in the abdomen with which the baby can be delivered through.
- D. The severance of the umbilical cord between mother and child.
Correct Answer: A
Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.
A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?
- A. Measuring oxygen saturation for a client who has dyspnea
- B. Inserting a rectal suppository for a client who is vomiting
- C. Performing nasal hygiene for a client who has an NG tube
- D. Pouching a client's ostomy bag for a new colostomy
Correct Answer: D
Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.
You have just learned that another nurse was fired for taking photographs of patients without their permission using a cell phone and posting them on Facebook. This nurse was fired because the nurse had:
- A. Violated the law
- B. Acted in a negligent manner
- C. Not completed the proper documentation
- D. Violated an ethical principle
Correct Answer: A
Rationale: The correct answer is A: Violated the law. Taking and sharing patient photographs without consent is a violation of patient privacy laws, hence the nurse was fired for breaking the law. Choice B, acting in a negligent manner, is incorrect as the nurse's actions were intentional and not due to negligence. Choice C, not completing proper documentation, is unrelated to the situation described. Choice D, violating an ethical principle, is not specific enough as the primary reason for the nurse's termination was the legal breach regarding patient privacy.
Which patient is exercising their right to autonomy in the context of patient rights?
- A. An 86-year-old female who remains independent in terms of the activities of daily living.
- B. An unemancipated 16-year-old who chooses to not have an intravenous line.
- C. A 32-year-old who does not need the help of the nurse to bathe and groom themselves.
- D. A 99-year-old who wants CPR despite the fact that the nurse and doctor do not think that it would be successful.
Correct Answer: D
Rationale: The correct answer is D. A 99-year-old exercising their right to autonomy in the context of patient rights by choosing CPR. Autonomy in healthcare refers to the patient's right to make their own decisions about their care, even if healthcare providers may disagree. In this scenario, the 99-year-old patient is exercising autonomy by making an informed choice about their medical treatment, despite healthcare professionals having a different opinion. Choices A, B, and C do not directly demonstrate the exercise of autonomy in decision-making regarding medical treatment, making them incorrect.