A. "Why are you changing your mind about the procedure?" This question may come across as confrontational or judgmental. It does not directly address the client’s need for information or support.
B. "This procedure is perfectly safe." This response is dismissive and provides false reassurance. The nurse should avoid minimizing the client's concerns.
C. "I will contact the provider to let her know." When a client expresses uncertainty about undergoing a procedure, the nurse's priority is to notify the provider. The provider is responsible for addressing the client’s concerns, clarifying the procedure, and ensuring informed consent. The client's autonomy must be respected, and they have the right to withdraw consent at any time.
D. "You should discuss your concerns with your family!" While family support can be helpful, the decision to proceed or not is ultimately between the client and the provider. Directing the client to the family may undermine their autonomy.

A. Obtain informed consent from the client for the blood transfusion: Verifying that informed consent is obtained is essential, but obtaining consent is the provider's responsibility. The nurse's role is to ensure the consent has been signed and documented.
B. Delegate the client's care to an RN: If the nurse receiving the shift report is already an RN, delegating the care to another RN is unnecessary unless there are specific time constraints or workload considerations.
C. Access the nursing information system for guidelines about blood transfusions: This is an appropriate action to ensure that institutional policies and guidelines are followed regarding blood administration, which may include steps for patient identification, infusion rates, and monitoring for reactions.
D. Inform the charge nurse of the need to reassign the client's care: This is typically not necessary unless the assigned nurse lacks the competency to administer blood products or has competing responsibilities that prevent safe monitoring of the transfusion.

A. AU (both ears): This abbreviation is not recommended because it can be misinterpreted as referring to the eyes (OU) or ears (AU). The Joint Commission discourages using abbreviations that can lead to errors.
B. ADL (activities of daily living): This is a widely accepted and standardized abbreviation in healthcare documentation. It is not prone to misinterpretation.
C. HS (hour of sleep): HS can be misinterpreted as "half-strength." Therefore, it is not recommended for use in documentation according to best practice guidelines.
D. SQ (subcutaneous): SQ can be misread as "SL" (sublingual) or mistaken for "5 every." The recommended abbreviation is "subcut" or "subcutaneous."

A. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day.": This is unnecessary and may cause confusion. "Twice per day" is clear and less prone to misinterpretation during verbal communication.
B. Verify the medication name along with its intended purpose: This is a critical safety measure to ensure that the prescribed medication is appropriate for the client and to prevent errors related to look-alike or sound-alike drug names.
C. Remind the provider to countersign the prescription in 72 hr: This is essential to meet legal and institutional requirements, but it is not the most immediate priority when confirming the prescription.
D. Transcribe the medication name using the trade name: Using generic names is preferable in healthcare documentation to avoid confusion caused by multiple trade names for the same medication.

Client 1 (First Priority):

• Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
• Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

• Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
• Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

• Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
• Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.

A. Documenting false information in a client’s medical record: This constitutes fraud or falsification rather than negligence.
B. Restraining a client without a provider’s prescription: This action is considered false imprisonment, a type of intentional tort, not negligence.
C. Threatening to administer a medication a client has refused: This is classified as assault, an intentional tort.
D. Failing to notify the provider after a medication error: Negligence involves failing to act in a way that a reasonably prudent nurse would under similar circumstances. Failing to notify the provider about a medication error compromises client safety and demonstrates a breach of duty.

A. Establish eye contact with the other person: Maintaining eye contact demonstrates attentiveness and respect during communication, fostering trust.
B. Passively listen to the other party: Passive listening is ineffective and may lead to misunderstandings. Active listening is preferred for conflict resolution.
C. Use "you" rather than "I" statements to express thoughts: "You" statements can be perceived as accusatory and escalate conflicts. "I" statements help express concerns without blame.
D. Focus on the person, not the problem: Effective conflict resolution focuses on addressing the problem, not assigning blame or targeting individuals.

A. Notify the nurse manager: Informing the manager may be necessary later, but the immediate priority is assessing and addressing the family member's condition.
B. Check the family member's vital signs: Assessing the family member's condition is the first step to determine the severity of the situation and provide appropriate care.
C. Obtain the family member's health history: Health history is valuable but not a priority in an acute event like fainting.
D. Complete an incident report: Incident reporting is necessary but should occur after the situation is managed and the family member's condition is stabilized.

A. Close the door to the client's room: This helps contain the fire and prevents smoke from spreading, but it should not be the immediate action after client removal.
B. Activate the alarm outside the client's room: Activating the alarm is critical after ensuring the client's safety, as it alerts the facility to the emergency and mobilizes response teams.
C. Use a Class A fire extinguisher to contain the fire: The type of extinguisher used depends on the fire classification. Attempting to extinguish a fire should occur only after the alarm is activated.
D. Turn off electrical equipment in the client's room: While turning off electrical equipment can reduce fire hazards, it is not the next priority after removing the client.

A. Tell the client's partner the charge nurse can provide the results: The charge nurse would still be bound by HIPAA regulations and cannot share the client's information without consent.
B. Tell the client's partner the results of the laboratory tests: Sharing health information without the client’s permission violates HIPAA regulations.
C. Tell the client's partner not to worry about the results: This response dismisses the partner's concerns and does not address the privacy issue.
D. Tell the client's partner to ask the client about the results: This is the appropriate action, as the client has the right to choose whom to share their health information with.