A nurse is caring for a client who is a local public official. A newspaper reporter repeatedly phones the unit seeking information and states, "The public
... [Show More] has a right to know the health status of elected officials." Which of the following actions should the nurse take?
A. Acknowledge that the person is a client on the unit but give no specific details of the client's condition.
B. Refer any calls directly to the client's room so that the client and her family can decide what to tell the press.
C. Refer all media inquiries to the nursing supervisor.
D. Hang up on media callers because nursing staff members are not required to speak to them. - C.
Refer all media inquiries to the nursing supervisor.
The HIPAA Privacy Rule prohibits disclosing client information to individuals who are not involved in care without the client's express consent. The reporter should be told that, due to confidentiality issues, no information can be given about any client. The nurse should refer the reporter to the nursing supervisor.
Incorrect Answers:
A. The HIPAA Privacy Rule prohibits disclosing client information to individuals who are not involved in care without the client's express consent.
B. The nurse should not forward the call to the client's room because this will disclose the hospitalization.
D. Hanging up on callers from the news media is unprofessional. The nurse should refer calls to the nursing supervisor.
/
A nurse is speaking with the family member of a client who has early Alzheimer's disease. The family member would like to keep the client living at home, but the client requires assistance while the family member is away at work. Which of the following services should the nurse include in the discussion?
A. Hospice care
B. Adult day care
C. Assisted-living facility
D. Long-term care facility - B.
Adult day care
Adult day care personnel can provide constant assistance with ADLs while the family member is at work; the client can live at home during the night and evening hours.
Incorrect Answers:
A. Hospice care is only appropriate for a client who has a terminal illness and a life expectancy of <6 months.
C. Clients who live in an assisted-living facility need to be able to live independently and require minimal assistance. Clients can receive assistance with medication and are offered one prepared meal a day if needed. However, an assisted-living facility is not an option at this time since the family member wishes to keep the client at home.
D. A long-term care facility is not an option at this time since the family member wishes to keep the client at home.
/
A nurse is performing a safety audit on all equipment used on the unit. Which of the following items should the nurse identify as a safety hazard?
A. An electrical cord that is taped to the floor
B. A protective cover that is placed over an unused outlet
C. An electrical cord that is frayed toward the plug
D. An electrical plug that has 3 prongs - C.
An electrical cord that is frayed toward the plug
The nurse should identify that an electrical cord that is frayed toward the plug is damaged and should not be used. Using an electrical cord that is damaged can increase the client's risk of acquiring an electrical shock.
Incorrect Answers:
A. An electrical cord taped to the floor prevents others from tripping over the cord or damaging it.
B. A protective cover placed over an unused outlet prevents young children from playing with the outlet.
D. An electrical plug with 3 prongs is a grounded piece of equipment, which provides a path of low resistance to stray electric currents. This is the only type of electrical equipment that should be used.
/
A nurse is planning care for several clients. Which of the following clients should the nurse refer to a case manager?
A. A client who has neurological deficits following a stroke
B. A married female client who has delivered a full-term newborn
C. A client who is postoperative following a cholecystectomy
D. A child who has a fracture of the dominant arm - A.
A client who has neurological deficits following a stroke
The nurse should refer this client to the case manager for care. A client who had a stroke will likely require long-term treatment. A client who has ongoing needs for care or rehabilitation should receive care that is directed by a case manager due to the complexity and cost of the client's needs.
Incorrect Answers:
B. If no complications or social concerns exist, the delivery of a full-term newborn does not require case management.
C. As long as no complications occur, this procedure does not require a case management approach.
D. A child who has a fractured arm does not require a case management approach unless there is evidence that some other pathology precipitated the fracture.
/
An RN and a licensed practical nurse (LPN) are caring for a client who has a small bowel obstruction and is NPO with a nasogastric (NG) tube set to continuous suction. Which of the following tasks should the RN perform?
A. Obtain daily weight
B. Inspect the client's oral cavity for dryness hourly
C. Measure and record the NG tube output every 4 hours
D. Assess for bowel sounds every 2 hours - D.
Assess for bowel sounds every 2 hours
Assessments are within the scope of practice for the RN only. While the LPN can also auscultate the client's abdomen for the presence of sounds, only the RN is qualified to evaluate the sounds and qualify them as hypoactive, normal, or hyperactive.
Incorrect Answers:
A. Obtaining a daily weight is within the scope of practice of an LPN. While the RN could also perform this task, it should be delegated to an LPN so that the RN is available to perform other tasks.
B. Oral care is considered part of routine hygiene and includes observing the membranes of the mouth for dryness. It is within the scope of practice for the LPN. While the RN could also perform this task, it should be delegated to an LPN so the RN is available to perform other tasks.
//
A nurse is making a client's bed and finds a capsule of medication in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice? (Select all that apply.)
A. Administer the medication to the client.
B. Notify the provider.
C. Complete a variance report.
D. Document the finding in the client's electronic medical record.
E. Place the medication back in the medication drawer. - B. Notify the provider.
C. Complete a variance report.
B. Notifying the provider is correct. The nurse should notify the provider of the finding as a part of the variance reporting process.
C. Completing a variance report is correct. The nurse should complete an incident or variance report regarding the occurrence.
Incorrect Answers:
A. Administering the medication to the client is incorrect. The nurse should not administer the medication to the client, because the nurse does not know which dose of the medication the client missed. Administering the capsule now could result in an overdose if the client has recently taken the same medication.
D. Documenting the finding in the client's electronic medical record is incorrect. The nurse should not document the finding in the client's electronic medical record. The nurse should identify that information in the client's medical record is subject to attorney review should the client decide, for any reason, to file suit against the facility or the healthcare staff. Instead, the nurse should follow facility policy and report the incident to the nurse manager and risk management through the use of a variance report. In addition, the nurse should avoid documenting in the medical record that a variance report was filed because this can also allow for the variance report to be subpoenaed should the client decide to file suit.
E. Placing the medication back in the medication drawer is incorrect. The nurse should identify that medications that are no longer packaged are considered contaminated and should be discarded.
/// [Show Less]