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A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.
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A nurse is providing teaching to assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
- A. Secure the client's restraints with a square knot.
- B. Attach the restraints to the fixed portion of the frame of the client's bed.
- C. Remove the client's restraints every 2 hr.
- D. Allow 1 fingerbreadth between the restraint and the client's wrists.
Correct Answer: C
Rationale: The correct answer is C: Remove the client's restraints every 2 hr. This instruction is crucial to prevent complications such as skin breakdown, circulation impairment, and emotional distress. Restraints should be released every 2 hours to assess the client's condition, provide necessary care, and ensure safety. This practice also promotes mobility and prevents long-term consequences of prolonged restraint use.
Explanation for other choices:
A: Secure the client's restraints with a square knot - Incorrect. Restraints should be secured with a quick-release knot to ensure quick removal in case of an emergency.
B: Attach the restraints to the fixed portion of the frame of the client's bed - Incorrect. Restraints should be attached to the movable portion of the bed frame to allow for adjustments and prevent harm.
D: Allow 1 fingerbreadth between the restraint and the client's wrists - Incorrect. Restraints should be snug but not too tight to avoid injury or discomfort.
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
- A. A client who has a raised red skin rash on his arms, neck, and face
- B. A client who has active bleeding from a puncture wound of the left groin area
- C. A client who reports right-sided flank pain and is diaphoretic
- D. A client who reports shortness of breath and left neck and shoulder pain
Correct Answer: B
Rationale: The correct answer is B, a client with active bleeding from a puncture wound of the left groin area. This is the highest priority because active bleeding can lead to severe blood loss, shock, and death if not controlled promptly. Immediate intervention is needed to stop the bleeding, assess for further injuries, and ensure the client's stability. Choices A, C, and D describe concerning symptoms that require attention but do not pose immediate life-threatening risks like uncontrolled bleeding. Therefore, they are of lower priority. It is crucial for the nurse to prioritize clients based on the severity and urgency of their conditions to provide timely and appropriate care.
A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?
- A. The client's preferred time for bathing
- B. The belief that the client has a difficult relationship with his son
- C. The time the client received his last dose of pain medication
- D. The steps to follow when providing wound care
Correct Answer: C
Rationale: The correct answer is C: The time the client received his last dose of pain medication. This information is crucial for ensuring continuity of care and preventing medication errors. It helps the rehabilitation facility staff know when the next dose is due and if any additional pain relief is needed.
A: The client's preferred time for bathing is important for comfort but not as critical as pain medication timing in a transfer report.
B: The belief about the client's relationship with his son is not relevant to the client's immediate care needs during transfer.
D: The steps for wound care are important but should be included in a separate document or care plan, not necessarily in a brief change-of-shift report.
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home?
- A. Pipe cleaners
- B. Oxygen tank
- C. Obturator
- D. Cotton balls
- E. Petroleum jelly
Correct Answer: B,C
Rationale: The correct answers are B and C. Option B, an oxygen tank, is essential for providing supplemental oxygen if the client experiences any respiratory distress at home. Option C, an obturator, is crucial for reinserting the tracheostomy tube if it accidentally dislodges.
Pipe cleaners (A) are not necessary for tracheostomy care. Cotton balls (D) can leave fibers behind and are not recommended. Petroleum jelly (E) can cause aspiration if applied near the stoma.
A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?
- A. Request the client sign an informed consent.
- B. Encourage the client to reconsider their decision
- C. Communicate the client's decision to the provider.
- D. Provide care for the client using a sympathetic approach.
Correct Answer: C
Rationale: The correct answer is C: Communicate the client's decision to the provider. This is the most appropriate action as it ensures the client's wishes are respected while also involving the healthcare provider in the decision-making process. By communicating the client's decision, the nurse is upholding the client's autonomy and promoting patient-centered care. Option A is incorrect as the client's refusal of chemotherapy does not require informed consent. Option B is inappropriate as it undermines the client's autonomy by pressuring them to reconsider. Option D is not the best choice as it focuses on the nurse's approach rather than facilitating communication between the client and the provider.