secure restraints with a double knot offer toileting and nutrition every 2 hours ask for a new restraint order every 48 hours check restraints for proper placement and check the skin every 2 hours document the type of restraint, need for continued use, and trial release results
An RN is working with an LPN to care for a group of clients. Which client would the RN most likely assign to the LPN?
a client receiving blood following back surgery a client who has just returned from having a left heart catheterization a client with an arterial line who is on a nitroprusside drip to control blood pressure a client with an abdominal wound requiring dressing changes every 4 hours and PRN
The nurse is working in the ED when a client in labor comes in and says that she does not have health insurance, but wants to know if a doctor will see her. The nurse understands that the client’s right to emergency services, regardless of ability to pay, is provided by which piece of legislation?
HIPAA the Continuity of Care Act the Patient’s Bill of Rights the Code of Ethics for Nurses
The nurse is talking with a client who has been diagnosed with thyroid cancer. The client is asking about different treatment options. Which response by the nurse is most appropriate?
“There are several local support groups you can join after you have completed chemo.” “Don’t worry about it. Your doctor will explain the best course of treatment for you.” “What information has your health care provider shared about the different treatment options?” “I wouldn’t take chemo if I were you. I’ve seen so many clients…
The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?
allowing clients in a substance abuse facility to be interviewed by the media violating the HIPAA need to know rule releasing information about a minor without parental consent There is no violation.
The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse?
calcium 9.8 mg/dL sodium 137 mEq/L chloride 104 mEq/L potassium 3.1 mEq/L
The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client’s risk of skin breakdown?
high risk mild risk severe risk moderate risk
The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm × 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?
Stage I Stage II Stage III unstageable
The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.
hypertension; slow, labored breathing decreased urine output; warm, pink skin increased urine output; cool, clammy skin hypotension; weak pulse; cool, clammy skin