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A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
- A. Incident report completed.
- B. Client climbed over the side rails.
- C. Client was trying to get out of bed.
- D. Client found lying on floor.
Correct Answer: C
Rationale: Rationale: The correct answer is C because it accurately describes the situation based on the information provided. Documenting that the client was trying to get out of bed aligns with the roommate's report of the incident. This statement is factual and relevant to the client's condition.
Summary:
A: Incident report completed - Not relevant to documenting the client's actions during the fall.
B: Client climbed over the side rails - Assumes an action not reported by the roommate.
D: Client found lying on floor - Describes the outcome, but does not explain the cause of the fall.
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What is the primary focus of health promotion activities?
- A. To manage chronic diseases
- B. To educate patients about their health
- C. To prevent the onset of disease
- D. To identify and treat diseases early
Correct Answer: C
Rationale: The correct answer is C: To prevent the onset of disease. Health promotion activities aim to prevent illnesses before they occur by promoting healthy behaviors and lifestyles. This is a proactive approach that focuses on preventing diseases rather than managing or treating them after they have developed. Choice A focuses on managing existing conditions, choice B emphasizes educating patients after the fact, and choice D focuses on early detection and treatment rather than prevention. Preventing disease through health promotion is the most effective and cost-efficient approach to improving overall health outcomes.
Even though this is not easy, facilitating ____________ is a mandatory skill for all nurse managers and is crucial in the success of the manager.
- A. resistance
- B. change
- C. planning
- D. collection of data
Correct Answer: B
Rationale: The correct answer is B: change. Nurse managers often encounter resistance when implementing changes in healthcare settings. Facilitating change involves effectively managing resistance, promoting buy-in, and ensuring successful implementation. This skill is crucial for nurse managers to drive positive outcomes and improve patient care. Planning (choice C) and collection of data (choice D) are important skills but do not directly address the challenges of managing change. Resistance (choice A) is the opposite of what nurse managers aim to overcome when leading change initiatives.
When a policy violation occurs, what are the necessary steps for the nurse manager? (EXCEPT)
- A. Describing the staff nurse's behavior that violated the policy
- B. Terminating the staff immediately
- C. Confrontation
- D. Determining the employee's awareness of the policy
Correct Answer: B
Rationale: Correct Answer (B): Terminating the staff immediately
Rationale: Terminating the staff immediately is not the necessary step when a policy violation occurs. It is essential to follow due process, investigate the situation, provide the staff with the opportunity to explain themselves, and consider factors like intent, past behavior, and potential training needs. Rushing to terminate without proper investigation or understanding can lead to legal issues and unfair treatment.
Summary:
A: Describing the staff nurse's behavior - Important to clearly communicate the violation for transparency and understanding.
C: Confrontation - Addressing the issue directly and professionally is crucial for resolving conflicts.
D: Determining the employee's awareness - Assessing the employee's understanding of the policy helps identify training needs and prevent future violations.
When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Position the client in a side-lying position.
- B. Perform the irrigation using a 20-mL syringe.
- C. Instill 15 mL of irrigation fluid into the catheter with each flush.
- D. Measure and record the amount of irrigant used.
Correct Answer: B
Rationale: The correct answer is B: Perform the irrigation using a 20-mL syringe. This is the correct action because using a 20-mL syringe allows for precise and controlled instillation of the irrigation fluid into the catheter. Using a smaller syringe helps prevent excessive pressure within the catheter, reducing the risk of trauma or damage to the client's urinary system.
A: Positioning the client in a side-lying position is not essential for open irrigation technique, as long as the client is comfortable and the procedure can be safely performed.
C: Instilling 15 mL of irrigation fluid with each flush may not be appropriate as the volume needed may vary based on the client's condition.
D: Although measuring and recording the amount of irrigant used is important for documentation purposes, it is not the immediate action to ensure the safe and effective irrigation of the catheter.
Which of the following is an example of a clinical decision support system (CDSS)?
- A. Electronic health record (EHR)
- B. Barcode medication administration
- C. Smart infusion pumps
- D. Automated drug dispensing system
Correct Answer: C
Rationale: The correct answer is C: Smart infusion pumps. A smart infusion pump is an example of a CDSS as it helps healthcare providers in administering medications accurately by providing alerts, dosage calculations, and other decision support tools. This system enhances patient safety and clinical outcomes.
Incorrect choices:
A: Electronic health record (EHR) - While EHRs store and manage patient health information, they do not provide decision support features like CDSS.
B: Barcode medication administration - While barcoding helps in verifying medication administration, it is not a CDSS that provides clinical decision support.
D: Automated drug dispensing system - While these systems help in dispensing medications accurately, they do not provide clinical decision support tools like smart infusion pumps do.