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The nurse gives medical information regarding the client's condition to a person who is assumed to be a family member. Later the nurse discovers that this person is not a family member and realizes that this violated which legal concepts of the nurse-client relationship? Select all that apply.
- A. Duty to provide care
- B. Client's right to privacy
- C. Client's right of autonomy
- D. Client's right to confidentiality
- E. Duty to comply with nursing standards
Correct Answer: B,D
Rationale: Discussing a client's condition without client permission violates a client's rights to privacy and confidentiality and places the nurse in legal jeopardy. This action by the nurse is both an invasion of privacy and affects the confidentiality issue with client rights. Options 1, 3, and 5 do not represent violation of the situation presented.
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A client is admitted to the psychiatric unit after a suicide attempt. The nurse should plan which intervention as the most important to maintain client safety?
- A. Assigning a staff member to remain with the client at all times.
- B. Requesting that the client promise to alert staff of suicidal thoughts.
- C. Removing the client's personal clothing and replacing them with a hospital gown.
- D. Placing the client in a seclusion room where all dangerous articles are removed.
Correct Answer: A
Rationale: Hanging is a serious suicide attempt. The plan of care must reflect the action that will promote the client's safety. Constant observation by a staff member is necessary. It is not advisable to rely on the client to report suicidal thoughts at this point in the treatment. Removing one's clothing does not maximize all possible safety strategies. Placing the client in seclusion further isolates the client.
The nurse is assigned to care for a client who is in traction. Which intervention by the nurse should ensure a safe environment for the client?
- A. Making sure that the knots are at the pulleys sites
- B. Checking the weights to be sure that they are off the floor
- C. Making sure that the head of the bed is kept at a 90-degree angle
- D. Monitoring the weights to be sure that they are resting on a firm surface
Correct Answer: B
Rationale: To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. The head of the bed is usually kept low to provide countertraction. Weights are not to be kept resting on a firm surface.
An emergency department nurse is a member of an all-hazards disaster preparedness planning group. The group is developing a specific emergency response plan in the event that a client with smallpox arrives in the emergency department. Which interventions should initially be included in the plan? Select all that apply.
- A. Isolate the client.
- B. Don protective equipment immediately.
- C. Notify infectious disease specialists, public health officials, and the police.
- D. Lock down the emergency department and the entire hospital immediately.
- E. Identify all client contacts, including transport services to the emergency department and clients in the waiting room.
- F. Administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room immediately.
Correct Answer: A,B,C,E
Rationale: An all-hazards disaster preparedness group is a multifaceted internal and external disaster preparedness group that establishes action plans for every type of disaster or combination of disaster events. In the event of emergency department exposure to a communicable disease such as smallpox, the client would be isolated immediately and the staff would immediately don protective equipment. The emergency department would be locked down immediately. Locking down the entire hospital may not be necessary and infectious disease specialists and public health officials will determine whether it is necessary to take this action. Infectious disease specialists, public health officials, and the police are notified. All client contacts (name, addresses, telephone numbers), including transport services to the emergency department and clients in the waiting room, would be identified so that the public health department can follow through on notifying and treating these individuals appropriately. Although getting the vaccine within 3 days after exposure will help prevent the disease or make it less severe, it is unreasonable and unnecessary to administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room.
A client with a diagnosis of schizophrenia and psychosis is pacing, agitated, and presenting with aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Which priority nursing intervention based on these objective data should the nurse implement?
- A. Provide safety for the client and other clients on the unit.
- B. Bring the client to a less stimulated area to regain control.
- C. Provide the clients on the unit with a sense of comfort and safety.
- D. Assist the staff in caring for the client in a controlled environment.
Correct Answer: A
Rationale: If a client is exhibiting signs that indicate loss of control, the nurse's immediate priority is to ensure safety for all clients. Option 1 is the only option that addresses the client's and other clients' safety needs. Option 2 addresses the client's needs. Option 3 addresses other clients' needs. Option 4 is not client centered.
A primary health care provider prescribes 1000 mL of 0.45% normal saline solution to run over 8 hours. The drop factor is 15 drops/mL. The nurse plans to adjust the flow rate to how many drops per minute to safely administer this intravenous (IV) solution? Fill in the blank and round answer to the nearest whole number.
Correct Answer: 31
Rationale: The prescribed 1000 mL is to be infused over 8 hours. Follow the formula for calculating IV flow rates and multiply 1000 mL by 15 (drop factor). Then divide the result by 480 minutes (8 hours × 60 minutes). The infusion is to run at 31.2 or 31 drops/min.