A nurse is reviewing safety precautions with a group of youn...

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all.

A. Install bath rails & grab bars in bathrooms
B. Wear a helmet while skiing
C. Install a carbon monoxide detector
D. Secure firearms in a safe location
E. Remove throw rugs from the home

Correct Answer: B, C, D

Rationale: The correct recommendations for young adults are B, C, and D. Young adults are more likely to engage in activities like skiing that pose a risk of head injuries, hence wearing a helmet (B) is crucial. Carbon monoxide poisoning can occur from faulty heating systems or appliances, making it important to install a detector (C). Additionally, young adults may be more likely to own firearms, so securing them in a safe location (D) is essential to prevent accidents. Installing bath rails (A) and removing throw rugs (E) are more relevant to older adults to prevent falls.

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation?

A. "Right client"
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances

Correct Answer: B, C, E

Rationale: The correct answer is B, C, and E. The 5 rights of delegation are essential for safe and effective delegation. Right supervision/evaluation ensures appropriate oversight, feedback, and accountability. Right direction/communication emphasizes clear instructions and open communication. Right circumstances consider factors like workload and resources. Right client (choice A) and right time (choice D) are not part of the 5 rights of delegation. In summary, choices A and D are incorrect because they do not align with the established principles of delegation, while choices B, C, and E are crucial components for successful delegation.

A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication administration record, which of the following medications should the nurse administer?

A. Meperidine (Demerol) 75 mg IM
B. Fentanyl 50 mcg/hr transdermal patch
C. Morphine 2 mg IV
D. Oxycodone 10 mg PO

Correct Answer: C

Rationale: The correct answer is C: Morphine 2 mg IV. Postoperative pain management is crucial for patient comfort and recovery. IV morphine is a potent opioid analgesic that provides quick and effective pain relief. The IV route allows for rapid onset of action, making it suitable for severe pain like in this case. Meperidine (choice A) is not recommended due to its toxic metabolite accumulation risk. Fentanyl patch (choice B) has a delayed onset and is not ideal for immediate pain relief. Oxycodone PO (choice D) is a less potent oral option compared to IV morphine for severe pain.

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 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.

A. Increase in incisional pain
B. Fever & chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst

Correct Answer: A, B, C

Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include: A) Increase in incisional pain: Infection can cause localized pain. B) Fever & chills: Systemic signs of infection. C) Reddened wound edges: Classic sign of wound infection. Incorrect choices: D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.

A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:

A. Some clients exaggerate their level of pain
B. Pain must have an identifiable source to justify the use of opioids.
C. Objective data are essential in assessing pain
D. Pain is whatever the client says it is.

Correct Answer: D

Rationale: Step-by-step rationale for why answer D is correct:

1. Pain is a subjective experience: Pain perception varies among individuals, making it crucial to consider the client's own description.
2. Client-centered care: Acknowledging the client's self-report of pain is essential in providing effective and compassionate care.
3. Holistic approach: Recognizing the client's perspective on pain helps in addressing their physical, emotional, and psychological needs.
4. Trust and rapport: Valuing the client's self-assessment of pain fosters a trusting relationship between the nurse and the client.
5. Evidence-based practice: Research supports that self-reporting of pain is the most reliable indicator of pain intensity.

Summary:
- Choice A is incorrect as assuming clients exaggerate pain undermines their credibility and may lead to inadequate pain management.
- Choice B is incorrect as pain is not always identifiable, and opioids may be justified based on the client's report.
- Choice C is incorrect as relying solely on objective data overlooks the