Nokea
When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.
You may also like to solve these questions
A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select ONE that does not apply)
- A. Collaborating with an interdisciplinary team
- B. Implementing evidence-based care
- C. Providing family-focused care
- D. Experimenting on patients
Correct Answer: D
Rationale: The correct answer is D: Experimenting on patients. The IOM report emphasizes the importance of evidence-based practice, collaboration, and patient-centered care to ensure nurses are practicing at their highest levels of competency. Experimenting on patients is unethical and not a part of competent nursing practice. Nurses should rely on established evidence and best practices rather than experimenting on patients. Assessing nurses' competency in collaborating with teams, implementing evidence-based care, and providing family-focused care aligns with the IOM's recommendations for quality nursing practice.
It is hospital policy to assess and record a patient's heart rate before administering digoxin (Lanoxin). By auditing the nursing records to determine the frequency of compliance with this policy, the quality assessment and improvement committee is conducting
- A. a process analysis.
- B. a quality analysis.
- C. a system analysis.
- D. an outcome analysis.
Correct Answer: A
Rationale: Process analysis focuses on evaluating adherence to specific procedures.
A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct Answer: A
Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection.
Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.
While you are talking with the patient, she becomes confused and begins slurring her words. What would you expect the physician to do?
- A. Assess if the patient had an ischemic or hemorrhagic cerebral vasospasm (CVS).
- B. Administer thrombolytic agent (TPA) since this is within 3 hours of the cerebrovascular accident (CVA).
- C. Tell the patient to go home, get rest, and to call the physician in the morning if the symptoms continue.
- D. Admit the patient and place her on bed rest.
Correct Answer: B
Rationale: Thrombolytics can dissolve clots if administered within the therapeutic window.
What nursing action is most important initially for Ms. Jenkins with pneumococcal pneumonia?
- A. Administer humidified oxygen, as ordered
- B. Obtain an order for aspirin
- C. Auscultate the posterior basal segments for rales and rhonchi
- D. Explain the diagnosis to the patient
Correct Answer: A
Rationale: Oxygen therapy addresses hypoxemia, a primary concern in pneumonia.