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A charge nurse is reviewing documentation in the medical record from a newly licensed nurse.

Exhibits

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The client has a history of major depressive disorder and alcohol use disorder. They have had previous hospitalization which has included detoxification. The client is inappropriate and is a huge fall risk. The provider has denied this RN's requests for physical or chemical restraints. Currently, the ICU and progressive care unit are full, and the client is being admitted to this medical unit. They appear 'medically stable. The client is alert, oriented to self and location. Denies pain. Sitting up in bed. The partner is at bedside and said that their spouse is always complaining or arguing

The client is inappropriate and is a huge fall risk

The provider has denied this RN's requests for physical or chemical restraints

They appear 'medically stable

The partner is at bedside and said that their spouse is always complaining or arguing

the ICU and progressive care unit are full

the client is being admitted to this medical unit

Denies pain. Sitting up in bed

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

The nurse's documentation of the client being "inappropriate" is vague and unprofessional. Additionally, using the term "huge fall risk" without a specific assessment or plan to mitigate the risk (e.g., implementing fall precautions) is not adequate documentation. Further, the nurse’s reliance on physical or chemical restraints without exploring alternative interventions suggests a need for education on restraint use and patient safety practices.

The nurse's notes reflect a subjective description of the client's behavior as 'inappropriate' and 'complaining or arguing,' which is not objective or professional. It is important for nursing documentation to remain objective and to describe observed behaviors rather than labeling them. The statement that the client is "medically stable" should be supported by objective data rather than subjective observation, and it is important to note that mental health stability is also a crucial aspect of overall health.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. The client should sign the informed consent if they are alert, oriented, and capable of making decisions. The client's ability to understand the procedure and its implications is key to valid informed consent.

B. The client's son, who has a durable power of attorney would only sign the consent if the client were not competent or unable to understand the procedure, which is not the case here.

C. The client's partner may be involved in the decision-making process but does not have the legal authority to sign the consent unless designated as a legal representative.

D. The client's daughter, who is the primary caregiver would also not have the legal authority to sign the consent unless she holds a durable power of attorney or the client is deemed incapable of giving consent.

A. Lean gently over the back of a chair sitting to one side of the room when making the announcement. B. Cross her arms over her chest when beginning the announcement. C. Stare at the people the announcement will affect the most D. Sit in front of the group for the meeting and then stand for the announcement.

Correct Answer is D

Explanation

Rationale:

A. Lean gently over the back of a chair sitting to one side of the room may appear disengaged or unprofessional.

B. Cross her arms over her chest is a closed posture that may seem defensive or unapproachable.

C. Stare at the people the announcement will affect the most can be intimidating or uncomfortable for others.

D. Sit in front of the group for the meeting and then stand for the announcement is effective for emphasizing the importance of the announcement and engaging the audience.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

Correct Answer is A

Explanation

A nurse who is leading a team of nurse managers is planning to make a major announcement. The nurse should use which of the following nonverbal communication techniques to enhance the importance of the announcement?

Correct Answer is D

Explanation

A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN?

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)

An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

A nurse on a pediatric unit is caring for a child and his family. His parents define family as a husband, wife, and child. This definition is which type of family form?

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?

The charge nurse is planning to delegate client care tasks. Exhibits For each task identify the team member to which the nurse should delegate the task. Each task may be appropriate for more than 1 team member.