Nokea
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.
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A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
- E. Rosenbaum test
Correct Answer: A, B
Rationale: The correct tests to assess balance are the Romberg test and heel-to-toe walk. The Romberg test evaluates proprioception and balance by having the client stand with feet together and eyes closed. If the client sways, it indicates balance impairment. The heel-to-toe walk assesses gait and balance by asking the client to walk in a straight line placing the heel of one foot in front of the toes of the other foot. Choices C, D, and E are incorrect as they are not related to balance assessment. The Snellen test evaluates visual acuity, spinal accessory function assesses shoulder movement, and Rosenbaum test measures near vision acuity.
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
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
A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take?
- A. Offer to assist the client needing the bedpan.
- B. Administer the injection prepared by the other nurse.
- C. Prepare another syringe & administer the injection.
- D. Tell the client needing the bedpan she will have to wait for her nurse.
Correct Answer: A
Rationale: The correct answer is A. The second nurse should offer to assist the client needing the bedpan. This is important for patient safety and continuity of care. By offering assistance, the second nurse ensures that the immediate needs of the client are met promptly. Administering the injection prepared by the other nurse (B) may lead to errors and violates the principle of accountability. Preparing another syringe and administering the injection (C) is unnecessary and could delay care for the client needing assistance. Telling the client needing the bedpan to wait (D) is not appropriate as it neglects the client's needs.