The nurse is performing discharge teaching for a patient who has had major abdominal surgery.
Which statement or question by the nurse would be appropriate?
"You don't need to worry about anything.
We will get home health care set up for you.”.
"I heard your son was arrested for driving while intoxicated, will he be there to help you care for your incision?".
"I am sure you can't wait to go home.
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Providing non-slip footwear to patients during their stay is a good preventive measure, but it only addresses the risk of falls related to slippery floors. It does not address the overall fall risk, especially for elderly patients who may need constant supervision and assistance.
Choice B rationale:
Keeping the bed in a high position for ease of care might seem practical, but it increases the risk of falls when the patient attempts to get out of bed. Lowering the bed reduces the risk of injury if a fall occurs and is a more appropriate intervention.
Choice C rationale:
Instituting a policy requiring a sitter for all patients above the age of 60 is the best option among the choices provided. Elderly patients are at a higher risk of falls due to various factors such as weakened muscles, balance issues, and medication side effects. Having a dedicated sitter ensures constant supervision, timely assistance, and prompt intervention if the patient attempts to get out of bed, significantly reducing the risk of falls.
Choice D rationale:
Avoiding the use of a night light in the room to promote sleep is not a recommended intervention. While promoting sleep is essential for overall patient well-being, patient safety should always be the priority. Providing adequate lighting, especially at night, reduces the risk of falls and other accidents.
Correct Answer is C
Explanation
Choice A rationale:
The nurse is not responsible since the nurse was following the doctor's orders. Rationale: While it is essential for nurses to follow physician orders, they also have a responsibility to assess the appropriateness and safety of those orders. If the nurse administers a medication that is clearly harmful or beyond the normal dosage, they have a duty to question the order and seek clarification from the physician. Administering a medication that is twice the normal dosage without questioning the order would be a breach of the nurse's responsibility.
Choice B rationale:
Only the nurse was responsible since the nurse administered the medication. Rationale: While the nurse did administer the medication, the ultimate responsibility lies with both the nurse and the physician. The nurse should have questioned the order if it appeared to be incorrect or unsafe. Nurses are advocates for their patients and have a duty to ensure the safety and well-being of those under their care.
Choice C rationale:
Both the nurse and the physician are responsible for the error. Rationale: This is the correct choice. Both the nurse and the physician share responsibility for the error. The nurse should have questioned the order, and the physician should have prescribed the correct dosage. Patient safety is a collaborative effort, and both healthcare providers are accountable for ensuring that the patient receives appropriate and safe care.
Choice D rationale:
Only the physician is responsible since he or she ordered the drug. Rationale: While the physician did order the drug, the nurse also has a responsibility to assess the order and question it if necessary. Nurses are trained to use their clinical judgment and critical thinking skills to ensure the safety of their patients. If the nurse administers a medication without questioning a clearly incorrect dosage, they share responsibility for the error.
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