Nokea
A nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should the nurse document this in the client's chart?
- A. The client fell in the shower.
- B. The client states he fell in the shower & was able to get himself back into his chair.
- C. The nurse should not document this info because she did not witness the fall.
- D. The client fell in the shower & is now resting comfortably.
Correct Answer: B
Rationale: Correct Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
You may also like to solve these questions
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by the body's inability to regulate its temperature due to prolonged exposure to high temperatures. This leads to excessive sweating and dehydration, resulting in a drop in blood pressure (hypotension). Bradycardia (B) is a slow heart rate, which is not typically seen in heat stroke. Clammy skin (C) is common in heat exhaustion, not heat stroke. Bradypnea (D) is slow breathing, which is not a common sign of heat stroke. Therefore, hypotension is the most appropriate choice as it aligns with the pathophysiology of heat stroke.
An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is unlawfully restrained against their will. In this scenario, the nurse administering a sedative without the client's consent is considered an act of restraint, which restricts the client's freedom to leave. This action constitutes false imprisonment as the client is being detained without proper legal authority.
A: Assault involves the threat of harm or unwanted physical contact, which is not present in this situation.
C: Negligence refers to a failure to provide proper care or fulfill duties, which is not the case here.
D: Breach of confidentiality involves disclosing private information without consent, which is not relevant in this scenario.
In summary, the nurse committed false imprisonment by restricting the client's freedom of movement without legal justification.
A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by:
- A. Asking what precipitates the pain
- B. Questioning the client about the location of the pain
- C. Offering the client a pain scale to measure his pain
- D. Using open-ended questions to identify the situation
Correct Answer: C
Rationale: The correct answer is C: Offering the client a pain scale to measure his pain. This is the best way to assess the intensity of the client's pain objectively. Pain scales provide a standardized way for clients to communicate their pain levels, allowing for more accurate assessment and monitoring. Asking what precipitates the pain (choice A) focuses on triggers, not intensity. Questioning about the location of pain (choice B) is important but doesn't directly measure intensity. Using open-ended questions (choice D) may not provide a quantitative measure of pain.
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
- A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use
- B. Nail polish should not be used near a client who is receiving oxygen
- C. A 'No smoking' sign should be placed on the front door
- D. Cotton bedding & clothing should be replaced with items made from wool
- E. A fire extinguisher should be readily available in the home
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Nail polish should not be used near a client who is receiving oxygen to prevent a fire hazard as it is flammable.
C: A 'No smoking' sign should be placed on the front door to remind visitors not to smoke near the oxygen source.
E: A fire extinguisher should be readily available in the home to handle any fire emergencies related to oxygen use.
Incorrect choices:
A: Family members who smoke must be at least 10 ft from the client when the oxygen is in use is not as crucial as preventing ignition sources like nail polish.
D: Replacing cotton bedding & clothing with wool is unnecessary for oxygen safety.
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.