Nokea
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Obtaining an order for a restraint
- C. Assessing the patient's orientation
- D. Applying the restraint
Correct Answer: D
Rationale: The correct answer is applying the restraint (Choice D). Nursing assistive personnel can be delegated the task of applying restraints under the supervision and direction of a nurse. Determining the need for restraints (Choice A) and obtaining an order for a restraint (Choice B) involve clinical judgment and assessment, which are responsibilities of the nurse. Assessing the patient's orientation (Choice C) also requires a level of assessment that should be performed by a nurse.
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What is the most appropriate action for a healthcare provider to take when a patient refuses a prescribed medication?
- A. Document the refusal and notify the healthcare provider.
- B. Administer the medication at a later time.
- C. Explain the importance of the medication and its effects.
- D. Respect the patient's right to refuse the medication.
Correct Answer: D
Rationale: The correct answer is to respect the patient's right to refuse the medication. It is crucial to uphold the patient's autonomy and decision-making capacity when it comes to their treatment. Administering the medication later without the patient's consent (Choice B) disregards their autonomy and can lead to ethical issues. Documenting the refusal and notifying the healthcare provider (Choice A) is important for legal and continuity of care purposes but should come after respecting the patient's decision. While explaining the importance of the medication (Choice C) is valuable for promoting understanding and compliance, the immediate concern should be respecting the patient's refusal.
A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?
- A. Incomplete entries are acceptable as long as they are justified
- B. Documentation should include objective observations only
- C. Corrections in documentation should be signed and dated
- D. Entries should be modified by another healthcare professional if necessary
Correct Answer: B
Rationale: The correct answer is B. Proper documentation should include objective observations and detailed notes to ensure continuity of care. Choice A is incorrect because incomplete entries can lead to gaps in information and compromise patient care. Choice C is not completely accurate as corrections should be made in a manner that does not obscure the original entry but does not necessarily require a signature. Choice D is incorrect as entries should ideally be corrected by the original author to maintain accountability and accuracy.
After placing the patient back in bed, what should the nurse do next?
- A. Re-assess the patient.
- B. Complete an incident report.
- C. Notify the health care provider.
- D. Do nothing, no harm has occurred.
Correct Answer: C
Rationale: After placing the patient back in bed, the nurse should notify the health care provider. This is important because the health care provider needs to be informed of the incident and assess the patient further to ensure no underlying injuries or issues exist. Re-assessing the patient is crucial but notifying the health care provider takes precedence in this situation. Completing an incident report is important for documentation purposes but not the immediate next step. Doing nothing is incorrect as there was an incident involving a fall that needs further evaluation.
When considering a bone marrow transplant for a client with leukemia, which ethical principle pertains to minimizing harm to the client?
- A. Justice
- B. Nonmaleficence
- C. Autonomy
- D. Beneficence
Correct Answer: B
Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the ethical principle that emphasizes the obligation to do no harm, making it crucial in medical decision-making. In the context of a bone marrow transplant for a client with leukemia, the primary concern is to minimize harm and avoid causing any unnecessary suffering or adverse effects. Choices A, C, and D are incorrect: Justice relates to fairness in resource allocation and treatment decisions, Autonomy involves respecting the patient's right to make decisions about their own care, and Beneficence refers to the obligation to act in the patient's best interest and promote their well-being, which may involve some level of risk or harm for overall benefit.
A nurse manager assigns a task outside the scope of a nursing assistant. How should the assistant respond?
- A. Refuse the task and report it to the charge nurse.
- B. Perform the task without reporting.
- C. Ask another nurse to perform the task.
- D. Accept the task but document it later.
Correct Answer: A
Rationale: When a task is assigned that is outside the scope of a nursing assistant, it is essential for the assistant to refuse the task and report it to the charge nurse. This ensures that tasks are appropriately delegated, maintaining patient safety and adherence to professional standards. Performing the task without reporting can lead to potential risks for the patient and legal implications. Asking another nurse to perform the task may not address the issue of improper delegation. Accepting the task but documenting it later does not resolve the immediate concern of working within the assistant's scope of practice and seeking appropriate delegation.