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The experienced nurse is observing the new nurse providing care to the hospitalized cheat. Which action requires the experienced nurse to intervene to ensure client safety?
- A. Turns on the client's bathroom light and turns out the room lights after settling the client for sleep
- B. Checks the client's room number and name on the name band to verify client identity prior to giving a medication
- C. Stirs thickening powder into the glass of juice and cup of milk before giving these to the client who has dysphagia
- D. Delays the HCP from performing a thoracentesis by calling "a timeout" to verify the client's identity, consent, procedure, and site
Correct Answer: B
Rationale: Room number is not a unique client identifier. The nurse should use two unique identifiers, such as the client's name and medical record number, to verify identity before medication administration.
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The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
- A. Verify the order for the medication. Prior to giving the medication the nurse should say, 'Please state your name.'
- B. Upon entering the room the nurse should ask: 'What is your name? What allergies do you have?' and then check the client's name band and allergy band.
- C. As the room is entered say 'What is your name?' then check the client's name band.
- D. Verify the client's allergies on the chart and confirm the client's name on the name band.
Correct Answer: B
Rationale: Asking the client to state their name and allergies, then verifying with the name band and allergy band, ensures accurate identification and safety.
A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct Answer: A
Rationale: The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth.
A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to
- A. ask to not be assigned to this client or to work on another unit
- B. tell the client that such behavior is inappropriate
- C. inform the client that hospital policy prohibits staff to date clients
- D. discuss the boundaries of the therapeutic relationship with the client
Correct Answer: D
Rationale: Discuss the boundaries of the therapeutic relationship with the client. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct Answer: D
Rationale: After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.
A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?
- A. Her pregnancy is threatened, and the fetus is at risk for teratogenesis.
- B. She has a reportable condition, and the pregnancy must be terminated.
- C. Accutane is a Category D drug, which means it is unsafe in pregnancy.
- D. Her pregnancy must be followed carefully by a genetic specialist.
Correct Answer: A
Rationale: Accutane is a Category X drug, which means pregnancy is contraindicated due to teratogenesis associated with the medication.