A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Placing a client in restraints without having a healthcare provider’s order.

Administering the medication to a client behind a closed curtain.

Informing a client that the medication being administered is a vitamin.

Enlisting security personnel to assist with restraining the client.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Placing a client in restraints without having a healthcare provider’s order is a violation of patient rights and safety protocols. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety and well-being of the patient. Unauthorized use of restraints can lead to physical and psychological harm, and it is essential to follow established guidelines and obtain the necessary orders before applying restraints.

Choice B rationale

Administering the medication to a client behind a closed curtain is not a violation. This action ensures the client’s privacy and dignity during the administration of medication. Maintaining privacy is a standard practice in healthcare settings to respect the patient’s confidentiality and comfort.

Choice C rationale

Informing a client that the medication being administered is a vitamin is a violation of ethical and legal standards. It is essential to provide accurate information to the patient about the medication being administered. Misleading the patient can undermine trust and lead to potential harm if the patient has allergies or contraindications to the medication.

Choice D rationale

Enlisting security personnel to assist with restraining the client is not a violation if done appropriately. In situations where the client poses a danger to themselves or others, it may be necessary to involve security personnel to ensure safety. However, this should be done following proper protocols and with the necessary orders in place.

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Correct Answer is A

Explanation

Choice A rationale

Positive external places are often used in guided imagery to help clients focus on pleasant and calming environments. This technique can help distract from pain and promote relaxation by engaging the mind in a soothing and peaceful visualization.

Choice B rationale

Tranquil sounds can also be beneficial in relaxation techniques, but they are not the primary focus in guided imagery for chronic pain. Guided imagery typically involves visualizing a serene place rather than focusing solely on sounds.

Choice C rationale

Emotional reflection may not be as effective in reducing chronic pain through guided imagery. This technique is more about visualizing positive and calming environments rather than reflecting on emotions.

Choice D rationale

Motivational phrases are useful in other therapeutic techniques but are not the primary focus in guided imagery for chronic pain. Guided imagery focuses more on visualizing serene and peaceful places.

A. Using the syringe to remove the specimen from the catheter. B. Transporting the urine specimen to the laboratory. C. Recording the output on the flowsheet in the client’s room. D. Clamping the urinary catheter prior to the collection.

Correct Answer is A

Explanation

Choice A rationale

Using the syringe to remove the specimen from the catheter requires the nurse to wear gloves to maintain sterility and prevent contamination. Gloves protect both the nurse and the patient from potential pathogens present in the urine.

Choice B rationale

Transporting the urine specimen to the laboratory does not require gloves as the specimen is already secured in a biohazard bag, minimizing the risk of contamination.

Choice C rationale

Recording the output on the flowsheet in the client’s room does not involve direct contact with the urine specimen, so gloves are not necessary.

Choice D rationale

Clamping the urinary catheter prior to the collection does not require gloves as it is a preliminary step that does not involve direct contact with the urine.

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A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client’s attention on which focus?

Correct Answer is A

Explanation

The nurse uses a sterile syringe to obtain a urine specimen from a client’s indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is A

Explanation

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

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