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A nurse in an emergency department is caring for a client.

Exhibits

A nurse in an outpatient orthopedic clinic is caring for the client six weeks following surgical repair of a fractured radius. Which of the following information provided by the client indicates improvement?

Select all that apply.

The client has gained 1.8 kg (4 lb). BMI is 18.9.

The clients adult child prepares two meals per day for the client.

The clients clothing is clean and appropriate for the weather.

The client receives three baths per week from a home care aide.

The client reports frequent toothaches and lack of dental care.

The client makes eye contact and smiles when speaking.

Answer and Explanation

Correct Answer : C,F

Answer is… C and F indicate improvement.

A The client has gained 1.8 kg (4 lb). BMI is 18.9. This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.

B The clients adult child prepares two meals per day for the client. This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.

C The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.

D The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.

E The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.

F The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.

: https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture- wrist-fracture : https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.

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Correct Answer is C

Explanation

The correct answer is choice C. Administering potassium via IV bolus is an example of malpractice in nursing.

This is because potassium is a medication that can cause cardiac arrest if given too quickly or in high doses. A nurse who administers potassium via IV bolus is not providing the standard of care that a similarly trained nurse would have offered under the same circumstances.

This could result in harm or death to the patient.

Choice A is wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.

A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.

Choice B is wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.

A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.

It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.

Choice D is wrong because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice. A nurse

A. “The client was intubated without complications.” B. “There was a total of 10 sponges used during the procedure.” C. “The estimated blood loss was 250 milliliters.” D. “The client is a member of the board of directors.”.

Correct Answer is C

Explanation

This statement should be included in the hand-off report because it provides essential information about the patient’s intraoperative status and potential postoperative complications, such as hypovolemia, anemia, or infection. The estimated blood loss (EBL) is an important indicator of the patient’s fluid balance and hemodynamic stability.

Choice A is wrong because “The client was intubated without complications.” is not relevant for the postoperative care of the patient. The intubation status is usually documented in the anesthesia record and does not need to be repeated in the hand-off report unless there were any issues or injuries related to the airway management.

Choice B is wrong because “There was a total of 10 sponges used during the procedure.” is not pertinent for the postoperative care of the patient.

The number of sponges used during the surgery is usually counted and verified by the scrub nurse and the circulating nurse in the operating room to prevent any retained foreign bodies. This information does not need to be communicated to the PACU nurse unless there was a discrepancy or a missing sponge.

Choice D is wrong because “The client is a member of the board of directors.” is not appropriate for the hand-off report.

This statement violates the patient’s privacy and confidentiality and does not contribute to the quality or safety of care. The patient’s role or position in the organization should not influence the hand-off communication or the postoperative care.

A hand-off report is a critical communication tool that facilitates the transfer of care from one provider to another. It should include relevant information about the patient’s medical history, surgical procedure, intraoperative events, postoperative plan, and any concerns or potential problems.

A standardized hand-off tool, such as SBAR (Situation, Background, Assessment, Recommendation), can help improve the consistency, accuracy, and completeness of the hand-off report.

Some normal ranges that may be useful for postoperative care are:

Blood pressure: 90/60 mmHg to 120/80 mmHg
Pulse: 60 to 100 beats/min
Respiratory rate: 12 to 20 breaths/min
Oxygen saturation: 95% to 100%
Temperature: 36°C to 37.5°C
Hemoglobin: 12 to 18 g/dL
Hematocrit: 36% to 54%

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A nurse in an emergency department is caring for a client. Exhibits A nurse in an outpatient orthopedic clinic is caring for the client six weeks following surgical repair of a fractured radius. Which of the following information provided by the client indicates improvement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

Correct Answer is C

Explanation

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is C

Explanation

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