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A nurse is caring for a client who is postoperative and has a new prescription for incentive spirometry. Which of the following tasks should the nurse perform?
- A. Teach the client how to use the incentive spirometer.
- B. Assist the client with ambulation to the hallway.
- C. Measure the client's oxygen saturation every 4 hours.
- D. Document the client's daily intake and output.
Correct Answer: A
Rationale: Teaching the client how to use the incentive spirometer requires nursing expertise to ensure proper technique and understanding, which is essential for preventing postoperative complications like pneumonia.
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A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: C
Rationale: The correct answer is C: Battery. Battery is the intentional harmful or offensive touching of another person without consent. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes a deliberate act of touching the client without their consent, which aligns with the definition of battery.
False imprisonment (A) involves restricting a person's freedom of movement unlawfully, which does not apply in this case. Assault (B) involves the threat of harmful or offensive contact, not the actual act itself. Negligence (D) is the failure to exercise proper care in a situation, which is not applicable here as the action was intentional.
A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?
- A. Transporting a school-age client who is in traction to another department
- B. Reading a book to a preschool client who has AIDS
- C. Rocking an infant who was admitted for croup
- D. Playing a computer video game with an adolescent who has sickle cell disease
Correct Answer: A
Rationale: The correct answer is A because transporting a school-age client in traction requires specialized training to ensure proper handling and safety precautions. Traction devices are delicate and any mishandling could lead to injury. Reading a book to a preschool client with AIDS (B) promotes emotional support. Rocking an infant with croup (C) provides comfort. Playing a computer video game with an adolescent with sickle cell disease (D) promotes social interaction and distracts from pain.
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?
- A. Keeping an appointment with a client
- B. Allowing a new mother to hold her stillborn infant
- C. Confirming that a client going for surgery has signed a consent form
- D. Refusing to disclose information about a client to the media
Correct Answer: A
Rationale: The correct answer is A: Keeping an appointment with a client. Fidelity in nursing ethics refers to the nurse's obligation to be faithful and keep promises made to clients. By keeping an appointment with a client, the nurse is demonstrating reliability and honoring their commitment, which is essential for building trust and maintaining the therapeutic relationship. Choices B, C, and D do not directly relate to fidelity. Allowing a mother to hold her stillborn infant (B) is an example of compassion and emotional support, confirming a client's surgery consent form (C) is related to autonomy and informed consent, and refusing to disclose client information to the media (D) is about confidentiality and privacy, not fidelity.
A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?
- A. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
- B. The nurse uses clean gloves when discontinuing a client's intravenous infusion.
- C. The nurse uses the client's telephone number as one form of identification when administering medications to a client.
- D. The nurse empties a client's drainable colostomy pouch when it is one-third full.
Correct Answer: C
Rationale: The correct answer is C. Using a client's telephone number as identification is a violation of privacy and confidentiality. It is not a secure or reliable form of identification and could lead to errors in medication administration. The other choices do not indicate immediate intervention is needed. A: Opening the top flap of a sterile tray is incorrect but may not cause immediate harm. B: Using clean gloves for discontinuing an IV infusion is incorrect, but can be corrected easily. D: Emptying a colostomy pouch when it is one-third full is appropriate to prevent skin irritation and leakage.
A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?
- A. Inform the staff member of her appraisal time for that day prior to change-of-shift report.
- B. Schedule the appraisal interview as early in the shift as possible.
- C. Provide the staff member with a copy of the appraisal form in advance.
- D. Provide a chair directly across the desk for the staff member to sit in.
Correct Answer: C
Rationale: The correct answer is C: Provide the staff member with a copy of the appraisal form in advance. This action is essential as it allows the staff member to review the form, prepare their thoughts, and gather any necessary documentation or evidence to support their performance. By providing the form in advance, the staff member can actively participate in the appraisal process and engage in a meaningful discussion during the appraisal interview. This approach promotes transparency, fairness, and constructive feedback.
Other choices are incorrect:
A: Informing the staff member of the appraisal time prior to change-of-shift report may not give them adequate time to prepare for the appraisal.
B: Scheduling the appraisal interview as early in the shift as possible may not allow the staff member enough time to mentally prepare for the appraisal.
D: Providing a chair directly across the desk for the staff member to sit in is a physical setup and does not address the preparation aspect of the performance appraisal.