A nurse is giving an in-service to his colleagues on professional boundaries. Which statement by a fellow nurse indicates a need for further education on professional boundaries?

Because nursing involves personal information about the client, the nurse must be aware of boundaries

Dating a client is not ethical and it crosses a professional boundary

It is not a problem to tell the client about difficulties with my stepson

Accepting gifts from clients is generally not considered appropriate

Answer and Explanation

The Correct Answer is C

Choice A reason: This statement is correct. Nurses must be aware of boundaries because they handle sensitive personal information. Maintaining boundaries ensures professionalism and protects patient privacy.

Choice B reason: Dating a client is unethical and violates professional boundaries. Recognizing this is correct and does not indicate a need for further education.

Choice C reason: Sharing personal family difficulties with a client crosses professional boundaries. It shifts the focus away from the patient and places emotional burden on them. This statement indicates a need for further education because it demonstrates a misunderstanding of appropriate nurse-patient boundaries.

Choice D reason: Accepting gifts from clients is generally discouraged because it can create conflicts of interest or favoritism. Recognizing this is correct and aligns with professional standards.

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Correct Answer is C

Explanation

Choice A reason: This response is dismissive and delays addressing the patient’s emotional needs. While medications may help with pain, the patient’s anxiety and distress must be acknowledged and addressed immediately. Deferring the conversation does not provide therapeutic support.

Choice B reason: This response is inappropriate because it minimizes the patient’s feelings and pressures them to participate without addressing their concerns. Statements like “everyone gets nervous” lack empathy and do not validate the patient’s emotions.

Choice C reason: This is the correct response because it uses therapeutic communication. Sitting beside the patient, acknowledging distress, and inviting them to share feelings demonstrates empathy and builds trust. This approach helps reduce anxiety and allows the nurse to provide emotional support, which is critical for recovery and participation in therapy.

Choice D reason: Ignoring the patient’s distress is unsafe and unprofessional. Emotional well-being is an important part of recovery, and neglecting it can worsen anxiety, reduce cooperation, and negatively impact outcomes.

A. By placing the stethoscope over the chest and moving it until the heartbeat is detected. B. By locating the 5th intercostal space, mid-clavicular line then auscultating for 60 seconds. C. By placing the stethoscope directly on the center of the chest and auscultating for 30 seconds and multiply × 2. D. By locating the 3rd intercostal space, mid-axillary line then auscultating for 60 seconds.

Correct Answer is B

Explanation

Choice A reason: This method is imprecise and does not ensure accurate placement. Moving the stethoscope randomly until a heartbeat is detected may lead to incorrect readings, especially in patients on cardiac medications like Digoxin, where accuracy is critical.

Choice B reason: This is the correct method. The apical pulse is best assessed at the 5th intercostal space, mid-clavicular line, using a stethoscope for a full 60 seconds. This ensures accuracy, especially when monitoring for arrhythmias or bradycardia, which are potential side effects of Digoxin.

Choice C reason: This method is incorrect because auscultating for only 30 seconds and multiplying by 2 may miss irregular rhythms. Digoxin can cause bradycardia and arrhythmias, so a full 60-second count is necessary to detect abnormalities.

Choice D reason: This location is incorrect. The 3rd intercostal space, mid-axillary line does not correspond to the apical pulse site. Using the wrong anatomical landmark would result in inaccurate assessment.

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A nurse is giving an in-service to his colleagues on professional boundaries. Which statement by a fellow nurse indicates a need for further education on professional boundaries?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just had knee surgery 2 days ago and is scheduled for physical therapy (PT) now. The patient is nervous and crying. She does not want to get out of bed this morning. Which action by the nurse is most likely to be helpful in reducing the patient’s concerns?

Correct Answer is C

Explanation

The nurse needs to verify the apical pulse rate of his patient who takes Digoxin (cardiac medication). Which of the following is the best way to find an apical heart rate?

Correct Answer is B

Explanation

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