Unit 8 NCLEX

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"

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection

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 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

Which is a recommended guideline for safe computerized charting?

Accidental deletions from the computerized file needs to be reported to the nursing manager or supervisor.

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

Any PRN meds that were given during the shift

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 int he client's record concerning the incident.

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 signing the will. Many states prohibit employees from being a witness

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 identify tasks that can safely be performed.

A nurse lawyer provides an education session to the nursing staff regarding client rights. The nurse asks the lawyer to describe an example that may relate to invasion of client privacy. Which nursing action indicates a violation of client privacy?

Taking photographs of the client without concent

An unconscious client, bleeding profusely, is brought to the emergency department after a serious 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, as required by the health care provider, without obtaining an informed consent.