Saunders NCLEX-PN Ch. 6

Which identifies accurate nursing documentation?

> The client slept through the night > Abdominal wound dressing is dry and intact without drainage > The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management.

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 th eappropriate nursing action?

Decline to sign the will

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughtly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) 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.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements.

The nurse ovserves 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 several times. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identifiy tasks that can be safely performed.

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Taking photographs of the client without consent.

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

"I have a legal obligation to report this type of abuse."

An unconscious client, bleeding profusely, is brought to the emergency department after a serous accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately without obtaining an informed consent.