A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Countertransference

Boundary crossing

Promoting trust

Veracity

Answer and Explanation

The Correct Answer is C

A.   Incorrect. Countertransference refers to the nurse's emotional reaction to the client based on the nurse's personal feelings or past experiences.
B.   Incorrect. Boundary crossing refers to the nurse's actions that blur the professional boundaries of the nurse-client relationship, and this action does not necessarily represent boundary-crossing.
C.   Correct. The nurse's action of interrupting the bath to obtain a healthy meal for the client demonstrates an immediate response to the client's need and promotes trust and rapport between the nurse and the client.
D.   Incorrect. Veracity refers to truthfulness and honesty, but it does not directly apply to the nurse obtaining a meal for the client who is hungry.

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Correct Answer is C

Explanation

A. Tonicclonic seizures might be part of the electroconvulsive therapy procedure itself, but they would typically occur during the treatment, not 15 minutes after.
B. Paresthesias (tingling or numbness. are not a common expected finding following electroconvulsive therapy?
C. Correct. Disorientation is a common side effect after electroconvulsive therapy and usually resolves over time.
D. Sleep apnea is not an expected finding following electroconvulsive therapy.

A. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. B. A client received an 0900 daily medication at 1000. C. A client who has an infection refused the evening meal. D. A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. E. A client fell when ambulating to the bathroom alone.

Correct Answer is ["A","B","E"]

Explanation

The nurse should write an incident report for the following events:
1. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. This indicates a potential issue with the catheter or its proper functioning, which needs to be documented and addressed.
2. A client received an 0900 daily medication at 1000. This is a medication administration error as the medication was given later than the prescribed time. Medication errors should be reported and documented to ensure proper follow-up and prevent future occurrences.
3. A client fell when ambulating to the bathroom alone. Falls are considered significant incidents and should always be documented and reported to ensure appropriate evaluation, intervention, and prevention of future falls.
The following events do not require an incident report:
A client who has an infection refused the evening meal. While it is important to document a client's refusal of meals, it does not typically warrant an incident report unless there are specific concerns related to the client's health or safety.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. This may not require an incident report unless there are specific

circumstances or contraindications related to the timing of the antibiotic administration and blood collection, which need to be documented and reviewed.

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A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 minutes following the procedure?

Correct Answer is C

Explanation

A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse overhears two assistive personnel (AP. in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is caring for a client who has a prescription for levothyroxine. Which of the following laboratory tests should the nurse monitor?

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?