A nurse is assisting in the care of an older adult. The client appears to be malnourished and bruising is noted on their arms and legs. The nurse should identify which of the following as the legal responsibility of the nurse?

Notifying the caregiver of the findings.

Including findings during hand-off report.

Documenting suspicions in the client's medical record

Reporting findings to social services.

Answer and Explanation

The Correct Answer is D

A. Notifying the caregiver of the findings: If the caregiver is potentially involved in abuse or neglect, informing them directly could put the client at further risk. The nurse must follow appropriate reporting channels rather than confront the caregiver.

B. Including findings during hand-off report: While communication during hand-off is important for continuity of care, it does not fulfill the nurse’s legal obligation to formally report suspected abuse or neglect to the appropriate authorities.

C. Documenting suspicions in the client's medical record: Accurate and objective documentation of findings is important, but simply recording observations in the medical record does not meet the legal responsibility to report suspected abuse.

D. Reporting findings to social services: Nurses are mandated reporters and must legally report suspected abuse or neglect to the appropriate protective services. Reporting ensures that an investigation can occur to protect the client from further harm.

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Correct Answer is C

Explanation

A. A client who requires sterile dressing changes every three hours: Sterile dressing changes require skilled nursing care and must be performed by a licensed nurse. An assistive personnel (AP) is not trained or authorized to perform sterile procedures, making this assignment inappropriate.

B. A client who has a small bowel obstruction and requires insertion of a nasogastric tube: Inserting a nasogastric tube is an invasive procedure that requires clinical judgment and proper technique, which are responsibilities of licensed nursing staff, not assistive personnel.

C. A client who is postoperative and requires intake and output measurement every 2 hr: Measuring and recording intake and output is within the scope of practice for assistive personnel. It is a routine, noninvasive task that does not require nursing assessment or judgment.

D. A client on hospice who is unstable and requires frequent vital sign checks: An unstable hospice client requires close monitoring and clinical assessment. Although assistive personnel can measure vital signs, evaluating changes and determining their significance must be done by licensed nursing staff.

A. Apply restraints according to the facility's standing order. B. Obtain a PRN prescription for restraints from the provider. C. Stand in front of the client to block them from others in the room. D. Ensure there are enough staff members available for assistance

Correct Answer is D

Explanation

A. Apply restraints according to the facility's standing order: Restraints should never be applied based on a standing order. Each use of restraints requires a specific, immediate provider order following a thorough assessment of the situation.

B. Obtain a PRN prescription for restraints from the provider: PRN (as-needed) orders for restraints are not appropriate. Restraints must be ordered specifically when the need arises, after evaluating less restrictive measures.

C. Stand in front of the client to block them from others in the room: Standing directly in front of a combative client can escalate the situation and put the nurse at risk of injury. Maintaining a safe distance and using de-escalation techniques are safer strategies.

D. Ensure there are enough staff members available for assistance: Ensuring sufficient staff presence is critical when a client becomes combative. It helps ensure the safety of the client, other clients, and staff members, and allows for a coordinated response if physical intervention becomes necessary.

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A nurse is assisting in the care of an older adult. The client appears to be malnourished and bruising is noted on their arms and legs. The nurse should identify which of the following as the legal responsibility of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is making client assignments for the next shift. The nurse should assign which of the following clients to the assistive personnel?

Correct Answer is C

Explanation

A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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