Emergency
A nurse is reinforcing teaching to a group of clients about emergency care for a client who has a snake bite on a
leg. Which of the following information should the nurse reinforce in the teaching?
Immobilize the affected extremity with a splint.
A nurse makes a medication error. She immediately collects data from the client and finds no adverse effects from the error. The nurse decides not to report the error because no harm came to the client. Which of the following ethical principles did the nurse violate?
Veracity
A nurse is preparing an in-service for a group of newly licensed nurses about client confidentiality. The nurse should explain that they may share a client’s protected health information with which of the following groups?
Health care team members caring for the client
As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?
Keep a night light on in the client's room
A nurse is measuring an adult client’s tympanic temperature. Which of the following actions should the nurse take?
Insert the probe with a circular motion.
A nurse is reinforcing teaching with a group of clients about first aid care for a bee sting. Which of the following information should the nurse reinforce in the teaching?
Remove the stinger by scraping it off with a knife blade.
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions should he use as an example of a violation of confidentiality?
Reporting laboratory findings to a member of the client’s family
.A nurse is caring for a client who has a hip fracture that requires surgical repair. The nurse should identify which of the following health care professionals as responsible for obtaining informed consent from the client for the procedure?
Surgeon
.A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions is should the nurse take to help the client cope with his feelings of loss?
Listen attentively when the client talks about the past
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
Low BP and high pulse rate
A nurse is caring for a client when the safety on the bed plug’s electrical outlet pops and begins to smoke. Which of the following actions is the nurse’s priority?
Move any clients in the immediate vicinity.
A nurse is caring for an adult client who is competent and has refused an analgesic injection. The nurse administers the injection despite the client's objections. Which of the following types of tort has the nurse committed?
Battery
A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, 'My heart is racing.' The nurse notes that the client’s face has become flushed. Which of the following actions should the nurse take first?
Stop the transfusion
A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?
Turn the client on his side before starting oral care.
A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
Inability to regulate body temperature
A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?
Perform the Heimlich maneuver on the guest.
A nurse is caring for a client who is competent, refuses further treatment, and asks to sign out of the hospital against medical advice (AMA). The nurse notifies the charge nurse, who tells the nurse that the provider has recommended restraining the client, if necessary, to keep her from leaving the hospital. The nurse refuses to implement the action based on the knowledge that restraining this client would be committing which of the following torts?
False Imprisonment
With whom should a nurse should share her password for access to the facility's computer system?
No one
A nurse on a medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make?
"You will have to sign a written request for access to your record."
A nurse is collecting data about a client’s circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
Carotid
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
Maintain the patency of the client’s airway.
A nurse is documenting information in a client’s electronic medical record. Which of the following actions should the nurse identify as jeopardizing the confidentiality of the client’s data?
Sharing passwords for computer access with colleagues
A nurse observes an assistive personnel (AP) taking the call light away from a client and reprimanding him for using it frequently. Which of the following actions should the nurse take first?
Reassure the patient
A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, which of the following actions should the nurse take?
Include any relevant statements the client made about the incident.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
Count the apical pulsations for a full minute.