Nokea
A nurse observes a colleague failing to perform hand hygiene before entering multiple client rooms and administering medications. What is the most appropriate action by the nurse?
- A. Confront the colleague immediately in a client's room to stop the behavior
- B. Document the incident in the nurse's notes while monitoring for further issues
- C. Immediately report the behavior to the nurse manager for follow-up
- D. Assume the colleague is having a busy shift, and address it at a later time
Correct Answer: C
Rationale: Reporting to the nurse manager (C) ensures prompt follow-up on a serious infection control breach that risks client safety. Confronting in a client’s room (A) is unprofessional, documenting without action (B) delays intervention, and assuming busyness (D) ignores the safety violation.
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The nurse is developing a staff in-service on negligence. A participant demonstrates correct understanding by identifying which elements must be met in a negligence lawsuit? Select all that apply.
- A. Duty owed
- B. Breach of duty owed
- C. Causation
- D. Harm or damages
- E. Beneficence
Correct Answer: A, B, C, D
Rationale: Negligence requires duty owed (A), breach of duty (B), causation (C), and harm or damages (D). Beneficence (E) is an ethical principle, not a legal element of negligence.
The nurse in the emergency department (ED) is reviewing triage data for assigned clients. The nurse should initially follow up on the client who
- A. is requesting screening for pulmonary tuberculosis after traveling domestically in the United States.
- B. is being treated for a diabetic foot ulcer and requires a dressing change.
- C. is pregnant and has a fever accompanied by a generalized vesicular rash.
- D. is concerned they may have acquired human immunodeficiency virus (HIV) following unprotected sexual activity.
Correct Answer: C
Rationale: A pregnant client with fever and vesicular rash (C) suggests possible varicella or herpes, posing risks to mother and fetus, requiring immediate follow-up. TB screening (A), foot ulcer dressing (B), and HIV concern (D) are less urgent, as they are preventive or chronic.
The nurse is caring for assigned clients. The nurse should initially assess the client who
- A. is recovering from a femoral angioplasty and reports their foot is falling asleep.
- B. has diabetes mellitus and refused their prescribed glargine insulin.
- C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14.
- D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.
Correct Answer: A
Rationale: Numbness post-femoral angioplasty (A) suggests vascular compromise, such as occlusion, requiring immediate assessment. Insulin refusal (B), stable GCS post-alteplase (C), and constipation in spinal injury (D) are less urgent.
The nurse is providing the client with information regarding advanced directives. The nurse understands that giving this information supports the client's
- A. right to privacy.
- B. right to emergency care regardless of the ability to pay.
- C. C. self-determination.
- D. D. ability to receive appropriate treatment for their pain.
Correct Answer: C
Rationale: Advance directive discussions support self-determination (C) by empowering clients to make healthcare decisions. Privacy (A), emergency care (B), and pain treatment (D) are not directly related to advance directives.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP?
- A. Obtain a tympanic temperature for a client who received naproxen one hour ago
- B. Record and empty a closed suction drain for a client recovering from a mastectomy
- C. Assist a client in picking out low-sodium foods on their lunch menu
- D. Transport a client receiving an infusion of dopamine to the intensive care unit
Correct Answer: A
Rationale: Obtaining a tympanic temperature (A) is a routine task within UAP scope. Recording drain output (B), dietary education (C), and transporting a client on dopamine (D) require nursing judgment or monitoring.