Choice A rationale: Continuing to administer the medication and observing the client for adverse reactions is inappropriate in this scenario. Lack of training on the infusion pump poses a risk of medication errors, which could lead to patient harm. Proper operation of medical devices requires adequate training and understanding to ensure safety and effectiveness. Observing adverse reactions does not prevent potential errors during administration.

Choice B rationale: Notifying the charge nurse and requesting the client to be reassigned to another nurse is the correct action. Nurses must prioritize patient safety and act within their scope of competence. Communicating the lack of training ensures that the task is reassigned to a qualified nurse who can safely and accurately operate the infusion pump, minimizing risks associated with improper use.

Choice C rationale: Referring to the manufacturer's guidelines and proceeding to use the infusion pump is not the best approach. While guidelines provide technical instructions, nurses need hands-on training to fully understand and safely operate medical devices. Misinterpretation of the guidelines or insufficient familiarity with the pump's mechanisms can lead to errors, compromising patient safety.

Choice D rationale: Allowing another nurse to demonstrate the use of the infusion pump and then taking over may seem reasonable but is not ideal in this case. Demonstration alone cannot guarantee adequate competence, as proper training includes practice and assessment. The immediate priority is to ensure safe medication administration, which requires a trained and experienced nurse to handle the infusion pump directly.

Choice A rationale

Assignment abandonment involves leaving patients without care, which isn’t the nurse’s action here. The nurse stayed responsible and notified the charge nurse about equipment unfamiliarity to maintain ethical and safe practice standards.

Choice B rationale

Legal risks arise when a nurse uses medical equipment without validation, breaching competency and risking harm. Standards by regulatory bodies like the Joint Commission highlight the need for appropriate training, ensuring safe, error-free patient care.

Choice C rationale

Refusal of neonatal assignments does not connect to the case's circumstances. The legal concerns stem from equipment unfamiliarity, not from declining to work in specific units, which falls under staffing policies rather than individual liability.

Choice D rationale

Scope-of-practice violations occur when nurses exceed their authorized duties, but this doesn’t apply. The central issue involves patient safety risks due to equipment use beyond competence, aligning more closely with training and validation requirements.

Choice A rationale

Removing gloves outside an isolation room increases contamination risk by allowing pathogens to spread to other surfaces or areas. Standard precautions require immediate disposal of gloves inside isolation rooms to maintain strict infection control measures.

Choice B rationale

Encouraging clients to look down during ambulation aids balance and reduces fall risks. This recommendation follows safety guidelines and does not indicate incorrect AP behavior requiring intervention or correction by the nurse.

Choice C rationale

Maintaining a water temperature of 40° C (104° F) aligns with best practices for foot care, ensuring comfort and preventing skin damage. It does not necessitate intervention since this is a safe and appropriate nursing action.

Choice D rationale

Applying water-soluble lubricant to the nares reduces dryness from oxygen therapy, improving patient comfort. This practice aligns with evidence-based guidelines for oxygen care and does not warrant nurse intervention as it enhances client outcomes.

Choice A rationale

Morphine is classified as a Schedule II drug under the Controlled Substance Act. These substances have high abuse potential but accepted medical uses. Strict regulations on prescribing and dispensing help mitigate addiction risks while enabling pain management.

Choice B rationale

Schedule III drugs have lower abuse potential than Schedule II, such as anabolic steroids. Morphine’s classification reflects greater concern for dependency risks, making this categorization inaccurate given its pharmacological profile and misuse statistics.

Choice C rationale

Schedule IV substances, like benzodiazepines, pose even lower dependency risks. Morphine’s high potential for abuse makes it inappropriate to group with these drugs, highlighting its place in the more tightly regulated Schedule II category.

Choice D rationale

Schedule V includes medications with the least potential for abuse, like cough preparations containing small amounts of codeine. Morphine’s analgesic potency and risk profile far exceed those of Schedule V drugs, underscoring the inaccuracy of this classification.

Choice A rationale

Soft-serve ice cream contains dairy and sugar, which can worsen nausea for chemotherapy patients. Its high fat content may also contribute to gastrointestinal discomfort, making it an unsuitable food choice for managing nausea.

Choice B rationale

Hot tea, especially caffeinated varieties, may irritate the gastrointestinal lining and exacerbate nausea. While herbal teas could be soothing, this option does not explicitly align with the dietary recommendations for nausea management.

Choice C rationale

String cheese offers a protein-rich, low-fat option that is easy on the stomach and unlikely to exacerbate nausea. It aligns with dietary recommendations for managing chemotherapy-induced symptoms due to its mild taste and nutritional benefits.

Choice D rationale

Raisin toast contains fiber, which can be challenging to digest during nausea episodes, potentially worsening symptoms. Its texture and sweetness may also increase the risk of gastrointestinal upset, making it less suitable than other options. .

Choice A rationale

Suggesting long-term care placement may disregard the client’s autonomy and independence. Postoperative care often emphasizes rehabilitation and support, not institutionalization, unless medically necessary or preferred by the client. Autonomy is vital in discharge planning, aligning with patient-centered care principles.

Choice B rationale

Referral to social services connects the client with resources like home care or rehabilitation. Social workers can assess unmet needs and coordinate assistance, ensuring a safe discharge. Collaboration improves outcomes in individuals lacking support systems.

Choice C rationale

Ethics committees address dilemmas with moral implications, like end-of-life care. Discharge planning typically requires clinical and social assessment rather than moral adjudication. Engaging the ethics committee unnecessarily delays support.

Choice D rationale

Discharge timing is based on clinical readiness and does not hinge solely on the client’s social situation. Suggesting delay may not address unmet needs. Utilizing support resources is more constructive.

Choice A rationale

Speaking with other clients may inadvertently breach confidentiality. Additionally, client frustration with therapy often needs individualized attention to explore concerns, address misunderstandings, and rebuild trust.

Choice B rationale

Telling the client they cannot leave without a discharge prescription could infringe on their right to autonomy. Clients have the right to leave AMA (against medical advice) after understanding associated risks.

Choice C rationale

Informing the client that no additional treatment will be provided upon return is coercive and unprofessional. Healthcare professionals must maintain open access to care, even if the client initially refuses recommended therapy.

Choice D rationale

Having the provider discuss the care plan directly with the client can address misunderstandings about therapy and promote collaboration. This approach respects the client’s autonomy while clarifying potential risks of leaving.

Choice A rationale

Conducting change-of-shift reports in staff-only areas prevents unauthorized access to sensitive information. This aligns with HIPAA guidelines and ensures confidentiality. It also minimizes the risk of incidental disclosure to unauthorized individuals.

Choice B rationale

Logging others into unit computers compromises accountability and data security. Proper login ensures that only authorized personnel access confidential information, reducing risks of privacy breaches or documentation errors.

Choice C rationale

Placing the client’s name on cover sheets violates confidentiality if faxed to unintended recipients. Faxing protected health information requires de-identification or additional safeguards to comply with privacy regulations.

Choice D rationale

Identifying clients solely by room numbers introduces risks if materials are lost or misused. Although it obscures names, it fails to fully de-identify information. Education should emphasize secure handling of protected data. .

Choice A rationale

Consulting with the client’s family would delay critical actions in an emergency. Additionally, family members cannot override the legal documentation of the client's wishes, such as a living will. Ethical guidelines prioritize the client's autonomy, but without a written DNR, the nurse should prioritize immediate life-saving efforts.

Choice B rationale

A living will outlines patient preferences, but it is not legally enforceable without a corresponding provider’s order. Complying with it without a written DNR could violate legal and professional standards. The nurse must initiate life-saving actions unless explicitly instructed otherwise by the provider.

Choice C rationale

Without a written DNR, the nurse must take measures to preserve life as per standard resuscitation guidelines. Legal protection applies to actions taken during a cardiac arrest to avoid negligence. This ensures that the client receives immediate care until proper clarification is made.

Choice D rationale

Contacting the provider during a cardiac arrest introduces a delay, increasing the risk of irreversible damage or death. While it is essential to clarify orders, emergency protocol dictates acting promptly to save the client’s life in the absence of clear documentation.

Choice A rationale

Delaying surgery in an emergency violates the standard of care. When life-saving intervention is necessary, implied consent applies to act in the client’s best interests. Delaying for parental consent increases the risk of harm or mortality.

Choice B rationale

A pediatrician cannot grant consent in place of the legal guardians. Implied consent applies specifically to urgent situations where the client cannot consent, and the delay to contact a surrogate is not feasible.

Choice C rationale

A relative other than a parent or legal guardian cannot provide consent unless legally appointed. Emergency situations follow implied consent protocols when legal surrogates are unavailable. Proceeding with life-saving care does not require seeking extended family approval.

Choice D rationale

Implied consent is a legal principle used in emergencies to authorize necessary treatment when a legal guardian or proxy cannot be reached. This ensures timely intervention to prevent harm, especially for minors unable to consent themselves.