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A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
- A. Incident report completed.
- B. Client climbed over the side rails.
- C. Client was trying to get out of bed.
- D. Client found lying on floor.
Correct Answer: C
Rationale: Rationale: The correct answer is C because it accurately describes the situation based on the information provided. Documenting that the client was trying to get out of bed aligns with the roommate's report of the incident. This statement is factual and relevant to the client's condition.
Summary:
A: Incident report completed - Not relevant to documenting the client's actions during the fall.
B: Client climbed over the side rails - Assumes an action not reported by the roommate.
D: Client found lying on floor - Describes the outcome, but does not explain the cause of the fall.
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A client with limited mobility in their lower extremities is at risk for skin breakdown. Which of the following actions should the nurse take to prevent skin breakdown?
- A. Place the client in high-Fowler's position.
- B. Increase the client's intake of carbohydrates.
- C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.
- D. Have the client use a trapeze bar when changing position
Correct Answer: B
Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for skin health and wound healing. Carbohydrates provide energy for the body's healing processes. Skin breakdown can be prevented by ensuring the client has a well-balanced diet.
A: Placing the client in high-Fowler's position is not directly related to preventing skin breakdown in this scenario.
C: Massaging areas of skin that are darker than the surrounding skin tissue with lotion may cause more harm than good, as it can increase the risk of skin breakdown.
D: Having the client use a trapeze bar when changing position is important for mobility but does not directly address the prevention of skin breakdown.
What is the primary role of the nurse manager in risk management?
- A. Ensure compliance with regulations
- B. Report incidents to higher authorities
- C. Minimize risks to patients and staff
- D. Educate staff about safe practices
Correct Answer: C
Rationale: The primary role of the nurse manager in risk management is to minimize risks to patients and staff. This involves identifying potential risks, implementing strategies to prevent harm, and ensuring a safe environment. By minimizing risks, the nurse manager promotes patient safety and staff well-being.
A: Ensuring compliance with regulations is important but not the primary role of the nurse manager in risk management.
B: Reporting incidents to higher authorities is a part of risk management, but not the primary role of the nurse manager.
D: Educating staff about safe practices is crucial in risk management, but the primary role of the nurse manager is to minimize risks directly.
The ANA is a registered labor organization, but it does not engage in direct __________.
- A. Empower union affiliation
- B. Reward union affiliation
- C. Encourage union affiliation
- D. Collective bargaining
Correct Answer: D
Rationale: The correct answer is D: Collective bargaining. The American Nurses Association (ANA) is a professional organization representing nurses, not a labor union. Therefore, it does not engage in direct collective bargaining on behalf of its members. Collective bargaining is the process of negotiation between employers and employees, typically labor unions, to determine wages, working conditions, and other terms of employment. The other choices (A, B, C) are incorrect because the ANA focuses on professional development, advocacy, and promoting the interests of nurses rather than traditional labor union activities like empowering, rewarding, or encouraging union affiliation.
An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to
- A. give a bolus of 50% dextrose.
- B. insert a large-bore IV catheter.
- C. initiate oxygen via nasal cannula.
- D. administer glargine (Lantus) insulin.
Correct Answer: B
Rationale: The correct answer is B: insert a large-bore IV catheter. In HHS, patients are severely dehydrated due to high blood sugar levels. Inserting a large-bore IV catheter allows for rapid rehydration with isotonic fluids. This helps to correct the hyperosmolarity and electrolyte imbalances. Giving dextrose (choice A) would worsen hyperglycemia, initiating oxygen (choice C) is not directly related to managing HHS, and administering long-acting insulin like glargine (choice D) is not the initial priority in managing acute HHS.
When a policy violation occurs, what are the necessary steps for the nurse manager? (EXCEPT)
- A. Describing the staff nurse's behavior that violated the policy
- B. Terminating the staff immediately
- C. Confrontation
- D. Determining the employee's awareness of the policy
Correct Answer: B
Rationale: Correct Answer (B): Terminating the staff immediately
Rationale: Terminating the staff immediately is not the necessary step when a policy violation occurs. It is essential to follow due process, investigate the situation, provide the staff with the opportunity to explain themselves, and consider factors like intent, past behavior, and potential training needs. Rushing to terminate without proper investigation or understanding can lead to legal issues and unfair treatment.
Summary:
A: Describing the staff nurse's behavior - Important to clearly communicate the violation for transparency and understanding.
C: Confrontation - Addressing the issue directly and professionally is crucial for resolving conflicts.
D: Determining the employee's awareness - Assessing the employee's understanding of the policy helps identify training needs and prevent future violations.