Nlex unit 8

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next?

Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.

The licensed practical nurse (LPN) enters a client's room and finds the client sitting on the floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and health care provider (HCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which is accurate regarding immunity from this suit?

Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor.

A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action?

Notify the health care provider of the client's request.

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?

Assault

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will.

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action should be implemented?

obtaining a telephone consent from the family member and ensuring that the oral consent is witnessed by two persons