Nokea
A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?
- A. Fill the bath basin with tap water that is 39° C (102.2° F).
- B. Pull the curtain around the client's bed.
- C. Wash the client's arms and hands first.
- D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus.
Correct Answer: B
Rationale: The correct answer is B: Pull the curtain around the client's bed. This action ensures the client's privacy and maintains their dignity during the bathing process. By creating a physical barrier with the curtain, the nurse respects the client's autonomy and promotes a comfortable environment.
Choice A is incorrect because the water temperature specified may not be suitable for the client, as it is too hot. Choice C is incorrect as washing the arms and hands first may not be the most efficient or logical sequence for a full-body bath. Choice D is incorrect because wiping the client's eyes with a washcloth in that direction can introduce contaminants into the eyes.
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A charge nurse is evaluating the performance of an assistive personnel (AP). Which of the following actions by the AP indicates a need for further education?
- A. The AP reports a client's temperature of 38.5°C to the nurse.
- B. The AP assists a client with turning every 2 hours.
- C. The AP leaves a client's meal tray out of reach after delivery.
- D. The AP uses a gait belt when ambulating a client.
Correct Answer: C
Rationale: Leaving the meal tray out of reach prevents the client from eating, indicating a need for further education on client-centered care. The other actions are appropriate.
A charge nurse is planning care for a unit with limited staffing due to a flu outbreak. Which of the following actions should the charge nurse prioritize?
- A. Assign assistive personnel to provide client education on hand hygiene.
- B. Ensure all clients receive their scheduled baths on time.
- C. Reassess clients with unstable vital signs every 2 hours.
- D. Delegate documentation of intake and output to the unit clerk.
Correct Answer: C
Rationale: The correct answer is C: Reassess clients with unstable vital signs every 2 hours. This is the priority because clients with unstable vital signs require frequent monitoring to detect any deterioration or changes in their condition promptly. This action directly impacts patient safety and allows for timely intervention if needed.
Assigning assistive personnel for client education (A) is important for infection control but may not be the priority during a staffing shortage. Ensuring scheduled baths (B) is important for hygiene but can be delayed if necessary. Delegating documentation of intake and output (D) to the unit clerk is not appropriate as it involves clinical judgment and assessment.
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 nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
- A. Apply an ambulation alarm to the client's leg.
- B. Obtain a prescription to restrain the client PRN.
- C. Instruct the client in the use of the call light.
- D. Raise all side rails on the client's bed.
- E. Check on the client hourly.
Correct Answer: A,C,E
Rationale: The correct actions are A, C, and E. Applying an ambulation alarm to the client's leg helps prevent falls by alerting staff when the client attempts to get out of bed. Instructing the client in the use of the call light promotes safety by enabling them to request assistance when needed. Checking on the client hourly allows for monitoring and timely intervention if the client is at risk of falling. Choice B, obtaining a prescription to restrain the client PRN, is incorrect as physical restraints can have adverse effects and should be used as a last resort. Choice D, raising all side rails on the client's bed, is incorrect because it may lead to feelings of confinement and is not recommended as a fall prevention strategy.
A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit. Complete the following sentence by using the list of options.
- A. provide continuous monitoring of this client
- B. assess for readiness for release from seclusion
- C. clearly document reason for seclusion then obtain provider prescription for seclusion or restraints
- D. provide means for hygiene and elimination
- E. discuss reason for seclusion with client
- F. offer food and fluids
Correct Answer: A,C
Rationale: The correct answers are A and C. A is important to ensure the safety and well-being of the client, especially in a behavioral health unit where close monitoring is crucial. C is necessary to ensure proper documentation and adherence to protocols when seclusion or restraints are used. B is incorrect as assessing readiness for release from seclusion should only be done by a qualified provider. D is important but not as urgent as continuous monitoring. E is not appropriate as discussing the reason for seclusion with the client may not be beneficial during an acute episode. F is important but providing food and fluids should not be the priority over continuous monitoring and proper documentation.