A nurse is caring for a client who is exhibiting increased agitation. The nurse offered toileting, lowered the lights in the client's room and closed door to client's room.

Exhibits

Complete the following sentence by using the lists of options.

The nurse is at risk for
dropdown
as evidenced by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

False Imprisonment: This refers to the unlawful restraint of an individual's freedom of movement. By applying wrist restraints without a clear and immediate order from a provider or without proper justification, the nurse could be restricting the client's freedom of movement inappropriately.

Applying wrist restraints to the client: This action is a key factor in the potential for false imprisonment. Restraints should be used only when necessary and with proper authorization and documentation, particularly in non-emergency situations.

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Correct Answer is B

Explanation

Rationale:

A. Right circumstances refers to the appropriate conditions and setting for delegation.

B. Right supervision involves monitoring and evaluating the performance of tasks delegated to ensure they are completed correctly.

C. Right communication involves clearly communicating the tasks to be completed.

D. Right person ensures the task is delegated to someone with the appropriate skills and qualifications.

A. A client who has COPD and the capillary refill time on both hands is 4 seconds B. A client who has late-stage cirrhosis and whose breath has a fruity odor C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided

Correct Answer is D

Explanation

Rationale:

A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.

B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.

C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.

D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

Correct Answer is B

Explanation

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?

A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)

A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?

A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?