NUR 221 PrepU Safe and Effective Care Environment.

A charge nurse asks a group of staff nurses to cover part of the next shift because a nurse called off. A staff nurse states, "40 hours a week of nursing is all I can manage. I won't volunteer for overtime." The charge nurse tells the unit's nurse manager, "You should adjust her schedule to make her wish she'd volunteered." How should the nurse manager respond?

Counsel the charge nurse about her comment. Rationale: It would be discriminatory and punitive for the nurse manager to alter the staff nurse's schedule. The remark by the charge nurse is inappropriate and unprofessional, and the charge nurse should receive counseling. The nurse manager could choose to ignore the comment, but any leader who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the charge nurse to the nursing administration should be avoided. Institutional documentation should exist for such matters. It is inappropriate for the nurse manager to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

To prevent the spread of infection in the home health care environment, the nurse should follow appropriate technique by

Placing equipment bag on a liner when setting it down in the client's home. Rationale: To prevent the spread of infection, nurses should use appropriate technique when handling their equipment bags by performing hand hygiene before reaching into the bag for supplies, cleaning any equipment removed from the bag before returning it to the bag, and placing the bag on a liner when setting it down in the client's home. Donning gloves, a mask, or gown when greeting the client or family members is not necessary and will interfere with the greeting process.

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply.

The spouse places soiled dressing supplies in the kitchen garbage can. Sheets with wound drainage are washed in lukewarm water. Rationale: Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing dressing care.

The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence?

"How safe do you feel in your home?" Rationale: The act of screening for intimate partner violence is a key intervention to help open doors for at risk women to discuss ways to improve their safety and well-being. Asking clients how safe they feel in their home open is an open-ended, nonjudgmental way to elicit perceptions of safety.Asking if a partner is excited about a pregnancy is not a good screening question because many couples are not excited to learn of an unplanned pregnancy. However couples with healthy relationships eventually adjust.Having an arrest record and gun ownership do not automatically equate to having a history of violence.

The client becomes upset when the nurse asks if the client has an advance directive and states, "Why do I need an advance directive?" What is the most appropriate explanation for the nurse to give this client about an advance directive?

"Let's talk about how an advance directive enables you to have your health care preferences known to your health care providers." Rationale: The client's statement indicates a need to learn the purpose of an advance directive (which is to have the client's health care preferences made known to the health care providers). Inviting clients to talk about making decisions and stating their wishes about end-of-life care and health care treatment enables the clients to discuss what is important and culturally appropriate to them. An advance directive does not ensure the arrangement of ideal or optimal care in all medical circumstances, but assists the client to select desired care and a health care proxy. It gives the clients a voice in decision making and establishes that their wishes will be followed.

Which client should the nurse assess first?

A client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain. Rationale: The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.

Which client's care may a registered nurse (RN) safely delegate to the nursing assistant?

A client requiring assistance ambulating, who was admitted with a history of seizures. Rationale: The RN may safely delegate assistance ambulating for the client with a history of seizures to a nursing assistant. The RN should provide direct care to the client who requires continuous pulse oximetry monitoring because pulse oximetry interpretation requires assessment skills. Care of the clients requiring suctioning and patient-controlled analgesia can be safely delegated to a licensed practical nurse.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then

Advance both crutches. Rationale: The nurse should instruct the client to advance both crutches to the step below, then transfer their body weight to the crutches as they bring the affected leg to the step. The client should then bring the unaffected leg down to the step.

A nurse-manager must include which items as part of the personnel budget?

Anticipated overtime payments for staff. Rationale: Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Any expense or single item of equipment costing more than $500 is part of the capital budget. Office supplies and videos are part of the operating budget.

Which is the highest priority action by the nurse before starting this skill?

Assess stomach residual. Rationale: The picture provided is of a nurse administering a bolus tube feeding. Prior to administration, the highest priority would be to assess tube patency and stomach residual. Both can be accomplished by checking stomach residual. The client is placed in a Fowler's position for feeding, not supine. It is common to flush the tube after patency and residual are assessed. Bowel sounds are assessed as part of a routine assessment.

A nurse is finishing a shift on the pediatric unit. Because the shift is ending, which intervention takes priority?

Documenting the care provided during the shift. Rationale: Documentation should take top priority as this is the only way the nurse can legally claim that client interventions were performed. Checking client pain levels should be done throughout the shift and clients should be medicated so that they are not in need during busy change of shift times. Waiting until the end of the shift to review that client orders have been transcribed may lead to a delay in treatment and should be completed in a timely manner throughout the shift. Completing input and output recording can be assigned to a nurse assistant and should be delegated.

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do?

Find another nurse to cover the unit and send the nurse back to the surgery unit. Rationale: Nurses are accountable for their practice and must recognize the limitations of their own competency. To the extent possible, the nurse manager must ensure nurses working on their units have the required knowledge, skills, and competencies. The other options are incorrect because they do not ensure that the clients are receiving care from the most competent nurse.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?

Inform the anesthesiologist. Rationale: The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The preanesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask:

Is appropriate. Rationale: The mask is appropriate because it covers the nose and mouth and fits snugly against the cheeks and chin. The mask is not too low. Masks that are too large may cover the eyes. Masks that are too small obstruct the nose.

An unlicensed assistive personnel (UAP) is taking care of a child in the arm restraint shown in the figure. What should the nurse instruct the UAP to do to provide care for this child?

Leave the restraint in its current position. Rationale: The restraint should remain in position. Removing the restraint or untaping the restraint will risk dislodging the IV.

During an admission history a copy of the living will was provided by the client. The nurse's responsibility at this time is to:

Place the document on the client's chart and communicate the information to the health care team. Rationale: Living wills include instructions on when and how to implement their provisions, witness and testator requirements, immunity from liability for anyone following the directives, documentation requirements, and under what circumstances the living will takes effect. The document should be placed on the client's chart and the information shared with the health care team. Nurses do not need to ensure that all components are addressed, nor should the client keep the living will at the bedside.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do?

Remove all metal objects on the day of the scan. Rationale: Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations?

Review nationally published immunization guidelines. Rationale: National advisory committees on immunization practices review vaccination evidence and update recommendations yearly. Current vaccination catch-up schedules are readily available on their websites. The lack of vaccinations is a strong indicator that the child probably does not have a HCP. Even if the client had a provider, however, that person might be difficult to reach on a weekend during the timeframe of a vaccination clinic. If consulted, the pharmacist would most likely have to review the latest guidelines that are equally available to the nurse. Reading each of manufacturer's inserts for multiple vaccines would be time consuming, and synthesis of the information could possibly lead to errors.

When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next?

Rinse their eyes with water, report the incident, and go to Employee Health. Rationale: Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush their eyes with water. The nurse should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse their may allow viral transmission through contact with the mucous membranes.

A client is on a stretcher and needs to be transported to another location. Which action should the nurse take to prevent a personal injury when transporting this client?

Stand at the head of the stretcher and push the device. Rationale: Equipment should be pushed rather than pulled whenever possible. When transporting a client on a stretcher, the nurse should stand at the head of the stretcher and push, using the weight of the entire body and not just the arms. Pulling the stretcher with the arms or entire body is not appropriate because it would be safer for the device to be pushed. Standing at the side of the stretcher and pulling with the arms could cause injuries to both the arms and back from twisting the spine.

What should the nurse teach the parent of a 3-year-old child with eczema to remove from the child's environment at home?

Stuffed animals. Rationale: For the child with eczema, which is commonly related to an allergic response, stuffed animals should be avoided because they tend to collect dust and are difficult to clean.Metal toy trucks, plastic figures, and wooden blocks are suitable toys for a 3-year-old child. They are easy to keep clean.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which is a use of the medical record?

To investigate the quality of care in the agency. Rationale: Medical records may occasionally be used to investigate the quality of care in the agency. A medical record is not used to transmit health records between insurance companies, to inform family and others concerned about the client's care, or to release the entire health record for research, as these actions would jeopardize the individual's right to privacy.

A nurse is caring for a client with tuberculosis. Which infection-control technique is the priority when caring for this client?

Wearing an N95 respirator when caring for the client. Rationale: Because tuberculosis is transmitted via airborne droplets, the priority for nurses caring for this client is to wear an N95 respirator whenever entering the client's room. Performing hand hygiene before entering the room will not prevent the transmission of TB. When using a fit-tested N95 respirator, it is not necessary to limit the time spent with the client. Isolation gowns are not necessary for airborne isolation.

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required?

"I will heat my infant's formula in the microwave." Rationale: Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.

A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond?

"You seem worried about this assignment." Rationale: The RN assigning care should first give the UAP the opportunity to explore concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?

Perform thorough hand washing before and after touching any child in the day care center. Rationale: Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection.

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client?

Ask family members to wash their hands frequently. Rationale: The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the single most important preventive action. Insects do not transmit hepatitis A. Family members do not need to stay away from the client with hepatitis. It is not necessary to disinfect food and clothing.

A registered nurse is staff-shared to the maternal-neonatal unit where the RN has never worked before. How can this nurse be best employed?

Assign the RN a client care assignment in the postpartum unit. Rationale: The staff-shared nurse can be best employed in client care in the postpartum unit because such an assignment requires medical-surgical knowledge. In this setting, the nurse can safely use the RN's nursing skills and doesn't need to assume the role of a nursing assistant. The staff-shared nurse isn't qualified to work in the labor and delivery area or the nursery because both require specialized training to safely administer care.

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care?

Bending and twisting while providing care may cause injury. Rationale: Bending and twisting during routine care, such as bathing, should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as possible during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order. Rationale: After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

Identifying risks and ensuring future safety for clients. Rationale: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action and they are not commonly used to communicate within the interdisciplinary team.

The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. Which intervention will be most effective in preventing falls in this client?

Instruct the client to sit, obtain balance, dangle legs, and rise slowly. Rationale: There are many risk factors for falls in older adults. Postural hypotension is a common risk. The nurse should instruct the client about postural hypotension and provide practical information regarding how to sit on the bed or chair, dangle the legs first and then rise slowly, supported by a walker if necessary.A diary of instances of an individual's falls may predict future falls by tracking the events and behaviors at the time of the fall, but it is not the most effective in preventing the fall.Asking a family member to be present at all times is not necessary or realistic for this client whose fall risk is attributed to the potential for postural hypotension.Attaching a sensor to the client or bed is reserved for clients who are at a serious risk for injury.

Which nursing diagnosis takes highest priority for a client with a compound fracture?

Risk for infection related to effects of trauma. Rationale: A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

A nurse has custody of a client's daily Kardex and care plan so in order to give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality?

Shred the documents or place them in a container to protect confidentiality. Rationale: Kardexes, care plans, and other client documents contain confidential client information. The nurse should shred them or place them in a special confidential container for proper disposal. Regular garbage isn't secure and isn't an appropriate place to dispose of documents containing a client's name and information. Leaving the documents at the nurses' station may allow others to view them. It isn't necessary to place the nursing Kardex and care plan in the client's chart when the nurse has finished using them.

A nurse manager identifies fall prevention as a unit priority. Which actions can the nurses implement to meet these goals? Select all that apply.

Use bed alarms to remind clients to call for help getting up. Maintain a clear path to client bathrooms. Make hourly rounds to client rooms. Rationale: Client falls occur most often when there is need for assistance, but the client has not called for help. Frequent rounding, clear path to all bathrooms, and bed alarms for forgetful clients all have been shown to reduce client falls. Restraints should not be used without an order, or when a less-restrictive approach can be used. Closed doors at night will not reduce the risk for falls, but may increase them if the room is too dark or the nurses do not see the client in an unsafe situation.

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Rationale: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.

The nurse meets with a client in the outpatient clinic who is suicidal and refuses participate in creating a suicide safety plan. What should the nurse do next?

Arrange for immediate hospitalization on a locked unit. Rationale: A suicide safety plan is a written set of instructions to follow if a client begins to have self-harm thoughts. Plans are written by the client and care team when the risk for suicide is not considered high enough to warrant hospitalization. The nurse should arrange for immediate hospitalization on a psychiatric intensive care unit when the suicidal client refuses to help develop a safety plan. A psychiatric intensive care unit or locked unit is the appropriate setting and least restrictive environment to provide safety for a high-risk client. When clients are treated in an outpatient area, procedures must be in place for swift admission to an inpatient area that has a locked unit. The group home, a partial program, or a subacute unit would not provide the maximum safety that the client needs.

The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She is too upset by what is happening to make this decision." What should the nurse do?

Ask the client to sign the consent form. Rationale: Preparation for cesarean birth is similar to preparation for any abdominal surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain designated people can do so legally. The husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery may be performed without a written consent if it is done to save the life of the mother or the child, or both.

A client is admitted to the hospital. During the admission process, the nurse, the physician, and the pharmacist review the client's diagnosis and medications. The next person to see the client is a person from the admitting department. What is a rationale for the involvement of a person from the admitting department in the admission process?

It is a federal law that the institution provide a written summary of the client's health care decision-making rights. Rationale: Most hospitals, nursing homes, home health agencies, and HMOs routinely provide information on advance directives at the time of admission. They are required to do so under a federal law called the Patient Self-Determination Act (PSDA). The PSDA requires that most health care institutions (but not individual doctors) do the following: Give the client at the time of admission a written summary of the client's health care decision-making rights (each state has developed such a summary for hospitals, nursing homes, and home health agencies to use) and the facility's policies with respect to recognizing advance directives. Ask whether the client has an advance directive and, if so, document that fact in the client's medical record. (It is up to the client to give a copy to the institution.) Educate the staff of the institution and community about advance directives. Never discriminate against clients based on whether or not they have an advance directive. (It is against the law for health care institutions to require the client to have or not have an advance directive.)

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment. Rationale: It is helpful for the nurse to review the documented drug allergy listing and to use this as a basis for an assessment and discussion with the client. Drugs identified as contributing to an allergic reaction must be recognized and avoided as a serious risk to the client. It is poor practice not to pursue an allergy assessment simply because a client initially reports not being sure exactly what allergies are present; the client may respond well to prompting and an engaged interview. The goal of the nurse is to reach the most complete history and assessment possible with the client. Allergies can occur at any point in treatment, so the most recent allergies do not hold increased importance.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. What is the priority intervention to maintain safety for this client?

Assess reflexes, clonus, visual disturbances, and headache. Rationale: The central nervous system (CNS) functioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hypertension or stroke, oxygenation status is compromised, and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system, but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Increase the frequency of client observation. Rationale: The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem.

A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?

Sew thick padding into the elbows and knees of the child's clothing. Rationale: As the hemophilic infant begins to acquire motor skills, falls and bumps increase that risk of bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.

The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to PPE use?

"PPE should be used when you risk exposure to blood or bodily fluids." Rationale: Personal protective equipment or a barrier should be used when there is a risk that blood or other bodily fluids may come in contact with the nurse's skin or mucous membranes. This is a decision that can be independently made by the nurse and can be used when the nurse deems it appropriate. It is not necessary to use personal protective equipment or a barrier in every client contact. It is a nursing decision and does not need a physician's order.

A nurse is preparing a 24-hour-old baby boy for circumcision. The hospital policy guidelines for circumcision support pain medication at least 1 hour prior to the start of the procedure. The provider did not order the pain medication. The provider arrives, and the nurse refuses to bring the baby for the circumcision stating that the pain medication was not ordered. Which is the rationale for refusing to bring the baby for the procedure?

A nurse has a right to refuse orders that might be harmful to the client. Rationale: The nurse does have a right to refuse orders that might be harmful to the client. The nurse practice act of each state governs the practice of nursing. Each nurse should have a copy of the state practice act, the regulations, and any other official documents governing nursing practice for each state where the nurse is employed. All of these documents define the legal scope of nursing practice and guide and protect nurses in performing their duties.

When developing appropriate assignments for the staff, which client should the nurse manager judge to be at highest risk for suicide completion?

An 85-year-old Caucasian man who lives alone after his wife's death. Rationale: High-risk factors that have been related to suicide include hopelessness, Caucasian race, male gender, advanced age, living alone, previous suicide attempts, family history of suicide attempts, family history of substance abuse, general medical illnesses, psychosis, and substance abuse. The highest suicide rate is among people over the age of 65, particularly Caucasian males age 85 and over. Psychiatric diagnosis is considered to be the most reliable factor for suicide, especially for those with depression, schizophrenia, and substance disorders. Therefore, an 85-year-old Caucasian male who lives alone after his wife's death is at high risk for suicide completion.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation?

Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Rationale: Delegation must be clear and precise. The nurse-manager must assign responsibility, identify the task to be accomplished, explain the necessary outcomes, and define the time frame available to complete the work. The remaining options don't clearly define the work to be done, don't clearly assign responsibility or specify desired outcomes, or establish a time frame for completion of the task.

A severely confused client presents over the weekend at the emergency department with acute abdominal pain. The client cannot identify the illness, but reports receiving multiple medicines at the local free clinic each week. The best action the nurse caring for this client can take is to:

Complete the physical assessment and inform the physician. Rationale: The priority for the nurse remains to provide the best assessment possible, even without recent or remote treatment details. The nurse then should inform the physician of relevant findings. It is helpful to obtain and review available medical records, but this action is in support of the presenting symptoms and assessment by the nurse. Because of the client's confusion, it does not make sense to try to review local clinics in an effort to identify the treating clinic. In all likelihood the clinic will be closed as the client is presenting over a weekend. There is also no guarantee that the presenting symptoms are related to what the clinic may be treating. It is inappropriate to delay care to seek hospital staff who may have provided previous care for the client.

A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time?

Feelings of anxiety. Rationale: Anxiety is the top priority at this time. The client is exhibiting behavior that is indicative of anxiety, including restlessness, irritability, rapid speech, and inability to complete tasks. The other aspects of the nursing assessment are significant, but are not the top priority.

When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next?

Have the client put an "X" on the signature line. Rationale: The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary.

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first?

Obtain blood cultures. Rationale: All of the orders that the health care provider initiated are important but the nurse should obtain the blood culture before starting any other interventions—especially before starting the ampicillin. If the culture is obtained after a dose of ampicillin has been given, the results of the culture could be altered and unreliable.

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?

Hold the medication and report the information to the physician to ensure client safety. Rationale: The nurse should report the information to the physician because the client's safety may be endangered. The nurse shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

Which use of restraints in a school-age child should the nurse question?

To substitute for observation. Rationale: Restraints should never be used as a punishment or as a substitute for observation because if a child is at risk for self-harm when left alone, the child requires one-on-one observation. Ensuring the child's comfort or safety (restraining to keep an I.V., drainage tube, or orthopedic device in place), facilitating examination, and carrying out procedures are all valid reasons for restraint. Restraining devices aren't without risk and must be checked and documented every 1 to 2 hours.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?

Check on the client every 30 minutes while the restraints are on. Rationale: The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.

Which action most clearly demonstrates a nurse's commitment to social justice?

Lobbying for an expansion of Medicare eligibility and benefits. Rationale: Social justice is a professional value that encompasses efforts to promote universal access to healthcare, such as the expansion of publicly funded programs like Medicare. Culturally competent care is a reflection of human dignity while answering clients' questions and documenting accurately are expressions of the value of integrity.