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The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse-manager?
- A. Contact the healthcare provider to ensure that a prescription for restraints was written.
- B. Advise the staff nurse to remove the restraints from the client's wrists.
- C. Determine if the client has an as needed (PRN) prescription for an antianxiety agent.
- D. Close the door to the room to avoid disturbing other clients in nearby rooms.
Correct Answer: B
Rationale: Removing restraints prioritizes the client's autonomy and safety, avoiding harm from inappropriate use.
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The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
- A. Complete an adverse occurrence report.
- B. Obtain blood for coagulation studies.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: D
Rationale: Notifying the provider is critical to address the high bleeding risk from the medication error.
During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe an as needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. Which instruction should the nurse provide the unit clerk?
- A. Tell the healthcare provider the nurse will return the phone call as soon as possible.
- B. Remain with this client and monitor the vital signs while the nurse takes the call.
- C. Ask the healthcare provider to remain on 'hold' until the nurse can confirm the prescription.
- D. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.
Correct Answer: A
Rationale: The nurse must receive prescriptions directly, prioritizing the unstable client's care.
The healthcare provider discusses with a male client the need for a cardiac catheterization, describes the risks and benefits of the procedure, and asks the nurse to have the client sign the consent form. When the nurse presents the consent form for signature, the client hesitates and asks the nurse how the wires will keep his heart going. Which action should the nurse take?
- A. Call the client's next of kin and have them provide verbal consent.
- B. Explain the procedure again in detail and clarify any misperceptions.
- C. Notify the healthcare provider of the client's lack of understanding.
- D. Postpone the procedure until the client understands the risks/benefits.
Correct Answer: C
Rationale: Notifying the provider ensures the client's misunderstanding is addressed for valid informed consent.
A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family provides the client's signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Client's healthcare power of attorney.
- B. Increasing confusion of the client.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: B
Rationale: Increasing confusion is the urgent situation, indicating potential neurological deterioration.
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Heparin in Normal Saline prescribed for deep vein thrombosis.
- B. Regular Insulin in Normal Saline prescribed for ketoacidosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
Correct Answer: D
Rationale: Ceftriaxone can be safely administered via gravity drip over 30 minutes, unlike high-alert medications like heparin, insulin, or magnesium.