Nokea
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.
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The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who
- A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
- B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
- C. has a substance use disorder and refuses to attend group therapy for the second time.
- D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
Correct Answer: A
Rationale: Pacing and mumbling in psychosis (A) suggest agitation or worsening symptoms, posing a safety risk requiring immediate follow-up. Increased hand washing (B), therapy refusal (C), and abuse allegations (D) are less urgent, as they are chronic or procedural.
The nurse is caring for a client who expresses feeling self-conscious about their hair and states they would like to wash it before undergoing diagnostic tests and procedures. How should the nurse prioritize the client's care?
- A. Offer the client a cap or scarf to cover their hair and suggest washing it after the diagnostic tests are complete.
- B. The nurse should schedule the testing and meal planning first and complete hygiene as time permits.
- C. Perform the dressing changes first, schedule testing, counsel, and complete hygiene last.
- D. Arrange to wash the client's hair first, perform hygiene, and then complete the diagnostic testing and counseling.
Correct Answer: A
Rationale: Offering a cap/scarf and suggesting washing later (A) addresses the client’s emotional needs while prioritizing timely diagnostics, ensuring medical care is not delayed. Scheduling tests first (B), prioritizing dressings (C), or washing hair first (D) either delays care or ignores efficiency.
The nurse in the emergency department (ED) is caring for a client and establishes continuous cardiac monitoring. Which initial action should the nurse take based on the electrocardiogram tracing? See the exhibit for additional client information.
- A. Establish vascular access and request a prescription for atropine
- B. Assess the client's blood pressure and level of consciousness
- C. Obtain and review the client's current medications
- D. Document the findings and reassess the client in one hour
Correct Answer: B
Rationale: Sinus bradycardia can be benign or symptomatic. The priority is to determine whether the client is hemodynamically stable by assessing blood pressure (BP) and level of consciousness (LOC). If the client is symptomatic (e.g., hypotension, dizziness, altered mental status), further interventions such as atropine administration may be required.
The nurse in the family clinic is checking the vital signs of clients. Which client should the nurse prioritize?
- A. A 9-month-old baby with a pulse rate of 148
- B. A 2-year-old with a respiratory rate of 30
- C. A 24-week pregnant woman with a blood pressure of 148/96 mmHg
- D. A 40-year-old man with a temperature of 37.8°C (100.04°F)
Correct Answer: C
Rationale: A blood pressure of 148/96 mmHg in a 24-week pregnant woman (C) suggests preeclampsia, a priority for immediate assessment. A pulse of 148 (A) and respiratory rate of 30 (B) are normal for infants and toddlers, and a mild temperature (D) is less urgent.
The RN is the only RN in the assisted care facility on a busy evening shift. Of the following tasks, which ones can be safely delegated to an experienced LPN/LVN? Select all that apply.
- A. Completing an admission assessment on a new patient
- B. Administering routine oral medications to stable patients.
- C. Removal of a urinary catheter
- D. Completing a dressing change
- E. Administering an initial dose of a new medication to a patient.
Correct Answer: B, C, D
Rationale: Routine oral medications (B), urinary catheter removal (C), and dressing changes (D) are within an experienced LPN’s scope for stable patients. Admission assessments (A) and initial new medication doses (E) require RN judgment due to potential instability or adverse reactions.