nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's
... [Show More] provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?
A. Invasion of privacy
Rationale: Invasion of privacy is defined as failure to respect a client’s right to manage their own affairs.
This situation does not describe invasion of privacy.
B. Assault
Rationale: Assault is defined as threatening to inflict injury on a client or an attempt to do harm. This situation does not describe assault.
C. Battery
Rationale: Battery is defined as intentionally touching a client without her consent. This situation does not describe battery.
D. False imprisonment
Rationale: False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital.
2. An assistive personnel (AP) reports a client’s vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
A. BP
Rationale: A nurse who is supervising an AP's work is accountable for the work that the AP completes.
Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.
B. Respiratory rate
Rationale: This respiratory rate is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time.
C. Pulse rate
Rationale: This pulse rate is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time.
D. Temperature
Rationale: This temperature reading is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time.
3. A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
31 gtt/min
Correct Rationale: Follow these steps to calculate the infusion rate:
Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the volume the nurse should infuse? 250 mL
Step 3: What is the total infusion time? 2 hr
Step 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 1 hr/60 min = 2 hr/X min
X = 120 min
Step 5: Set up an equation and solve for X. Volume (mL)/Time (hr) x drop factor (gtt/mL) = X 250 mL/120 min x 15 gtt/mL = X gtt/min
31.25 = X
Step 6: Round if necessary. 31.25 = 31
Step 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads one 250-mL unit of packed cells to infuse IV over 2 hr, it makes sense to administer 31 gtt/min. The nurse should adjust the manual IV infusion to deliver the packed RBCs at 31 gtt/min.
InCorrect Rationale: Follow these steps to calculate the infusion rate:
Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the volume the nurse should infuse? 250 mL
Step 3: What is the total infusion time? 2 hr
Step 4: Should the nurse convert the units of measurement? Yes (min does not equal hr)
1 hr/60 min = 2 hr/X min X = 120 min
Step 5: Set up an equation and solve for X. Volume (mL)/Time (hr) x drop factor (gtt/mL) = X 250 mL/120 min x 15 gtt/mL = X gtt/min
31.25 = X
Step 6: Round if necessary. 31.25 = 31
Step 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads one 250-mL unit of packed cells to infuse IV over 2 hr, it makes sense to administer 31 gtt/min. The nurse should adjust the manual IV infusion to deliver the packed RBCs at 31 gtt/min.
4. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private,
positive-pressure airflow room. To which of the following rooms should the nurse assign the client?
A. 208
Rationale: A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.
B. 212 [Show Less]