file an incident report and document the finding in the client’s medical record document the finding in the client’s medical record only report the incident to the nursing supervisor file an incident report but do not document the finding in the client’s medical record
The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?
instruct the client to place a fan in front of the freezer to enhance circulation of cool air hold a meeting with the client and family to advise them of the safety risks of this practice note this observation in the client’s medical record, but do not discuss with the client report the incident to…
The nurse is preparing to do a 12-lead ECG on a client. Which of the following shows where the V1 lead should be placed?
site A site B site C site D
Which statement is incorrect regarding the Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87)?
the right to be free of unnecessary chemical restraints the right to choose a personal physician the right to access medical records the right to organize hospital personnel within a union
The nurse begins administration of blood to a client on a medical unit. The nurse knows that which of the following activities is inappropriate to delegate to the unlicensed assistive personnel (UAP)?
assist with bathing obtain a snack from the kitchen explain to the client the reason for the transfusion obtain the client’s blood pressure
A local politician is admitted to the emergency department. The nurse notices a staff member not involved with the care of this client reading his medical record. The nurse knows this is a violation of which of the following?
the Patient’s Bill of Rights the Patient Self-Determination Act the Health Insurance Portability and Accountability Act (HIPAA) the Uniform Anatomical Gift Act
The nurse is providing discharge instructions to the parents of a 6-month-old child with surgical repair for cryptorchidism. Which instruction would NOT be stressed?
observe surgical site for bleeding enforce bed rest for 2 – 3 days palpate scrotum to check testicle location avoid strenuous activity for at least one month
On the diagram, identify the location where the client would present with acute abdominal pain for the specified diagnosis.
Diagnosis Abdominal Location acute cholecystitis _______ acute appendicitis _______ acute cystitis _______ acute peptic ulcer _______ splenic infarction _______
The charge nurse is making an assignment for an LPN on an upcoming shift. Which assignment would be appropriate?
a client with a recent head injury and active seizures a post-operative patient requiring vital sign monitoring every hour a post-operative patient receiving a blood transfusion a client with diabetes requiring discharge instruction on insulin injection
The nurse is caring for a client with marked clubbing of the fingers and toes. The nurse understands which to be true regarding clubbing?
It is a permanent condition. Clients on dialysis often have clubbing. Sickle cell disease may cause clubbing. It is caused by acute oxygen deprivation. It can be caused by right-sided heart failure. It is common in clients with congenital heart defects.