The nurse caring for clients recognizes that there are several areas of potential liability in nursing practice. These include: (SELECT ALL THAT APPLY)

transferring a client to ICU without giving report.

completing the admission assessment.

documenting vital signs taken by another nurse.

calling the physician to request an order for pain medication for the client.

using an IV pump with a frayed cord.

Answer and Explanation

Correct Answer : A,C,E

A. This action could pose a significant liability risk as it violates the standard of care, which includes providing thorough and accurate handoff communication to ensure continuity of care. Failing to provide a report before transferring a client to ICU could lead to miscommunication, errors in treatment, and compromised patient safety.

C. Documenting vital signs taken by another nurse is generally acceptable as long as the nurse ensures the accuracy of the information and documents according to institutional policies and standards. However, if the nurse knowingly documents false or inaccurate vital signs, it could pose a liability risk.
E. Using equipment with a frayed cord poses a significant liability risk as it could lead to electrical hazards, equipment malfunction, or patient injury. Nurses have a duty to ensure the safety and integrity of equipment used in patient care and should promptly report any defects or safety concerns to prevent harm to patients.
B. Completing the admission assessment is a standard nursing responsibility and is not inherently a liability risk. However, liability could arise if the assessment is incomplete, inaccurate, or not documented appropriately, leading to errors in care or failure to identify and address the client's needs

D. Calling the physician to request an order for pain medication is a routine nursing responsibility and is not inherently a liability risk. However, liability could arise if the nurse fails to communicate important information about the client's condition or medication history, resulting in inappropriate or unsafe prescribing practices.

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Correct Answer is B

Explanation

B. This client's excitement to learn about a new prosthesis indicates a positive attitude towards rehabilitation and a willingness to engage in the learning process. Their enthusiasm suggests a high level of motivation to adapt to their new prosthesis and incorporate it into their daily life. Therefore, this client exhibits a high motivation to learn.
A. This client's struggle with following nursing directives regarding discharge goals suggests a lack of motivation or difficulty engaging in the rehabilitation process. They may be experiencing challenges or barriers that are impeding their progress. Therefore, they do not exhibit the highest motivation to learn at this time.
C. While this client may have valuable experience and insights to share with newcomers, being a "coach" does not necessarily indicate a high motivation to learn for themselves. While they may be motivated to help others, it doesn't necessarily reflect their own eagerness to engage in learning activities for their own rehabilitation goals.

D. This client's eagerness to be discharged may suggest a desire to move on from the rehabilitation facility rather than a motivation to engage in learning activities related to their rehabilitation. They may be more focused on the end goal of leaving the facility rather than actively participating in the rehabilitation process.

A. stoma is shiny and moist B. stoma is deep pink C. peristomal skin is not reddened or tender D. abdomen flat E. bowel sounds present 8 to 10 clicks/gurgles per minute

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

Explanation

A. A healthy stoma should appear moist and shiny, indicating adequate blood supply and hydration of the tissue. Dryness or dullness of the stoma may indicate poor blood flow or dehydration and should be further evaluated.
B. A healthy stoma typically appears deep pink to red in color, indicating good tissue perfusion. Pallor or cyanosis of the stoma may indicate inadequate blood supply and should be assessed promptly.
C. The skin around the stoma, known as the peristomal skin, should be intact, without signs of irritation, redness, or tenderness. Irritation or breakdown of the peristomal skin can occur due to leakage of stool or irritation from ostomy appliances and should be addressed promptly to prevent skin complications.
D. A flat abdomen suggests normal abdominal contour without distention or bulging. Distention or bulging of the abdomen may indicate underlying issues such as bowel obstruction, gas accumulation, or fluid retention and should be assessed further.

E. Bowel sounds are indicative of gastrointestinal motility and function. Normal bowel sounds are present and audible in healthy individuals and are characterized by 8 to 10 clicks or gurgles per minute. Absence or abnormal bowel sounds may indicate bowel obstruction, ileus, or other gastrointestinal disorders and should be assessed further.

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The nurse caring for clients recognizes that there are several areas of potential liability in nursing practice. These include: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is presenting teaching sessions to a group of clients in a facility for long-term physical rehabilitation. Which client exhibits the highest motivation to learn? The client who:

Correct Answer is B

Explanation

The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

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

Explanation

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