Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?
A. Contact the nurse manager.
Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Call risk management to interview the client.
Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassure the client that the staff is well trained.
Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Document in the client's chart that an incident report has been filed.
Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Leadership 2019 Proctored Exam. Take the full exam now
Full Explanation
A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
Similar Questions
A nurse is caring for a client who is unconscious, and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
A. "You should contact the provider about your wishes for your family member."
Directing the family member to contact the provider might not resolve the conflict between differing wishes of the family members.
B. "You should speak with the facility's ethics committee about your concerns."
In situations of conflicting decisions regarding a client's care, involving the ethics committee can provide a forum for discussion and resolution while considering ethical, legal, and moral aspects.
C. "As the health care surrogate, the client's partner can make this decision."
While the health care surrogate typically has decision-making authority, if there'sdisagreement among family members, involving an ethics committee or legal advisors can help navigate the situation.
D. "We'll need to have the nursing supervisor review the client's advance directives."
Reviewing advance directives might provide information, but the situation here involves conflicting wishes among family members that require a more nuanced approach, potentially involving ethical considerations.
Full Explanation
A. Contacting the provider may be part of the process, but it does not directly address the conflict between the family members' wishes and the health care surrogate's legal authority.
B. While the ethics committee can be a valuable resource in resolving disputes, it is not the first step in this situation, as the health care surrogate has the legal right to make decisions on behalf of the unconscious client.
C. The health care surrogate is legally designated to make health care decisions for the client when they are unable to do so themselves. This includes decisions about life-sustaining treatments such as a feeding tube.
D. Reviewing the client's advance directives is important, but it does not supersede the authority of the health care surrogate unless the directives explicitly limit the surrogate's decision-making power.
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?
A. Child protective services
Child protective services deal with cases of child abuse or neglect, which isn't relevant to the parent's inability to afford medical equipment.
B. Respiratory therapist
While a respiratory therapist might assist with the use of the nebulizer, they may not address the financial concerns of the parent.
C. Social worker
Social workers can help connect families with resources, financial assistance programs, or charitable organizations that may assist with obtaining necessary medical equipment.
D. Pharmacist
While a pharmacist plays a role in medication management, they may not directly address the financial concerns related to acquiring the nebulizer.
Full Explanation
A. Child protective services deal with cases of child abuse or neglect, which isn't relevant to the parent's inability to afford medical equipment.
B. While a respiratory therapist might assist with the use of the nebulizer, they may not address the financial concerns of the parent.
C. Social workers can help connect families with resources, financial assistance programs, or charitable organizations that may assist with obtaining necessary medical equipment.
D. While a pharmacist plays a role in medication management, they may not directly address the financial concerns related to acquiring the nebulizer.
A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?
A. Is the client's family present so the AP can show them how to turn the client?
While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Has the AP checked the client's pain level prior to turning her?
Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Does the AP have time to change the client's central IV line dressing after turning her?
Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Has data been collected about specific client needs related to turning?
Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.
Full Explanation
A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.