A nurse is assisting in the care of an older adult. The client appears to be malnourished and bruising is noted on their arms and legs. The nurse should identify which of the following as the legal responsibility of the nurse?

Notifying the caregiver of the findings.

Including findings during hand-off report.

Documenting suspicions in the client's medical record

Reporting findings to social services.

Answer and Explanation

The Correct Answer is D

A. Notifying the caregiver of the findings: If the caregiver is potentially involved in abuse or neglect, informing them directly could put the client at further risk. The nurse must follow appropriate reporting channels rather than confront the caregiver.

B. Including findings during hand-off report: While communication during hand-off is important for continuity of care, it does not fulfill the nurse’s legal obligation to formally report suspected abuse or neglect to the appropriate authorities.

C. Documenting suspicions in the client's medical record: Accurate and objective documentation of findings is important, but simply recording observations in the medical record does not meet the legal responsibility to report suspected abuse.

D. Reporting findings to social services: Nurses are mandated reporters and must legally report suspected abuse or neglect to the appropriate protective services. Reporting ensures that an investigation can occur to protect the client from further harm.

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Correct Answer is B

Explanation

A. Disposes of contaminated sheets in a linen bag: Contaminated linens should be placed in a designated leak-proof bag, often specifically marked for contaminated items. Simply disposing of them in a regular linen bag without proper precautions could lead to the spread of infection.

B. Wears clean gloves when performing oral hygiene: Wearing clean gloves during oral care is an effective and appropriate use of supplies to maintain standard precautions and protect both the client and the caregiver from potential contamination.

C. Empties the sharps container when it is full: The sharps container should be emptied when it is three-quarters full, not completely full. Waiting until it is full increases the risk of needlestick injuries and improper disposal practices.

D. Wears an N95 mask when bathing a client who has Clostridium difficile: For Clostridium difficile, the appropriate personal protective equipment includes gloves and a gown, not an N95 mask. C. difficile is transmitted via contact with spores, not through airborne particles.

A. Show the client pictures that illustrate the surgery. B. Provide the client with written information in the client's primary language C. Provide the client with a professional interpreter to explain the surgery D. Ask a member of the client's family to discuss the surgery with the client. E. Ask the client if they understand the risks of the surgery

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

Explanation

A. Show the client pictures that illustrate the surgery: Visual aids can help bridge language barriers by providing a clear understanding of complex procedures. Pictures can reinforce verbal explanations and improve the client's ability to comprehend the surgical process, especially when language proficiency is limited.

B. Provide the client with written information in the client's primary language: Providing written materials in the client's native language ensures that the client has access to accurate, understandable information. This supports informed consent and allows the client to review the details at their own pace, enhancing comprehension.

C. Provide the client with a professional interpreter to explain the surgery: Using a professional medical interpreter is crucial for accurately conveying medical information. It ensures the client fully understands the procedure, risks, and benefits, which is necessary for informed consent and legal protection of client rights.

D. Ask a member of the client's family to discuss the surgery with the client: Family members should not be used as interpreters because they may lack medical knowledge and can introduce bias or inaccuracies. Relying on family could compromise the client's understanding and confidentiality.

E. Ask the client if they understand the risks of the surgery: Simply asking if the client understands without first ensuring effective communication through appropriate language services does not guarantee true understanding. The nurse must first use proper communication tools, like an interpreter or translated materials.

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A nurse is assisting in the care of an older adult. The client appears to be malnourished and bruising is noted on their arms and legs. The nurse should identify which of the following as the legal responsibility of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute appendicitis and speaks a different language than the nurse. The client is scheduled to undergo an appendectomy. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A nurse is contributing to the plan of care for a client who has a new ileostomy. Which of the following actions should the nurse include?

A nurse is monitoring a young adult client for risk-taking behavior. Which of the following statements by the client indicates they are limiting their risk-taking behavior?

A nurse is assisting with the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

A nurse is administering an enteric-coated medication to an adult client who has right-sided weakness and is having difficulty swallowing tablet. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting with the care of client who is 6 hr postoperative. Which of the following findings should the nurse report to the provider?