A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Check the client's medical record for the provider's prescription.

Inform the charge nurse that the client refused the enema.

Explain to the client that the provider prescribed the procedure.

Assure the client that enemas are commonly prescribed for constipation.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.

B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.

C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.

D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Client 3: Collect and label specimen.

Assistive personnel- Assistive personnel can handle the collection and labeling of specimens, which is a routine task that does not require advanced clinical judgment.

Client 1: Perform prescribed procedure.

Practical Nurse- Insertion of a nasogastric tube is a procedure that requires clinical skills and knowledge, making it appropriate for a licensed practical nurse (LPN) to perform.

Client 3: Administer prescribed medication.

Practical Nurse- Administering medication is within the scope of practice for a practical nurse, as they are trained to handle medications and monitor their effects.

Client 4: Perform prescribed testing.

Assistive personnel- Testing such as using a glucometer for blood glucose monitoring can be performed by assistive personnel under the supervision of a registered nurse or practical nurse.

Client 4: Provide prescribed wound care.

Practical Nurse- Wound care, especially for a non-healing wound and cellulitis, requires clinical assessment and skills that a practical nurse is trained to provide.

Client 2: Transport client for diagnostic testing.

Assistive personnel- Transporting clients to diagnostic testing is a task that can be safely performed by assistive personnel.

A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving. B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge. D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.

Correct Answer is B

Explanation

Rationale:

A. Applying restraints to prevent an alert, oriented client from leaving AMA: This is an example of false imprisonment, not negligence.

B. Negligence is the failure to act as a reasonably prudent nurse would under similar circumstances. Notifying the provider hours after discovering absent peripheral pulses shows a delay in appropriate action, which can lead to serious complications (e.g., compartment syndrome, tissue ischemia). This failure to act promptly meets the definition of negligence.

C. Administering medication without the client’s knowledge after refusal: This constitutes battery, as it involves intentional, unauthorized physical contact.

D. Threatening to apply restraints if the client continues eating chips: This is assault, since it is a threat of harm without physical contact.

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A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

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Naxlex Comprehensive Predictor Exams

The charge nurse is planning to delegate client care tasks. Exhibits For each task identify the team member to which the nurse should delegate the task. Each task may be appropriate for more than 1 team member.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?

Correct Answer is B

Explanation

An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?

A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?

A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

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?