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Make a copy of the incident report for the physician
Place the incident report on the client’s chart
Document a complete entry in the client’s record concerning the incident
Document in the client’s record that an incident report has been completed
A duty existed and it was breached
Not calling the physician
The dietary department sending the wrong food
The nurse’s persistence
The nurse manager assigns tasks to the staff members
Critical paths are used in providing client care
A single registered nurse (RN) is responsible for planning and providing individualized nursing care
Nursing staff are led by an RN leader in providing care to a group clients.
The donor must be 18 years of age or older
The donation is done by written consent
The family is responsible for making that decision at the time of death.
Clients have the right to donate their own organs for transplantation
Elevate the head of the bed
Close the client’s eye
Place wet saline gauze pads and an ice pack on the eyes
Close the client’s eyes and place a dry sterile dressing over the eyes
Represents a primary health prevention managed by a single case manager
Manages the client care by managing the client care environment
Designed to promote appropriate use of hospital personnel and material resources
Maximizes hospital revenues while providing for optimal outcome of client care
Assist a 12-year old boy who is profoundly developmentally disabled to eat lunch
Obtain frequent oral temperatures on a client
Accompany a 51-year-old man, being discharged to home following a bowel resection 8 days ago, to his transportation
Collect a urine specimen from a 70-year old woman admitted 3 days go
A client is performing own colostomy care
A 1-day postoperative client has a temperature of 98 degrees F
Purulent drainage is noted from a postoperative wound incision
A new diabetic client is preparing own insulin for injection
Prone, with the head turned to the side supported by a pillow
Sims’ position, with the head of the bed flat
Right side-lying, with the head of bed elevated 45 degrees
Left side-lying with the head of the bed elevated 45 degrees
A hitch knot was used to secure the restrain
The client’s record indicates that the restraint was released every 2 hours
The restraint was applied tightly to prevent a fall
The call light was placed within reach of the client
Turn on the water. Allow warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keeps hands pointed downward. Rinse the hands. Dry the hands using a paper towel.
Turn the water faucet off with the paper towel. Turn on the water. Allow the warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keep hands pointed upward. Rinse the hands. Dry the hands using a paper towel. Turn the water faucet off with the paper towel.
Turn on the water. Allow the warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keep the hands pointed down ward. Rinse the hands using a paper towel. Turn the water off with the clean hands.
Turn on the water; allow the cold water to wet the hands. Apply soap to the hands and rub it vigorously. Keep hands pointed upward. Rinse the hands using a paper towel and warm water. Turn the water off with clean hands.
Gown, mask and sterile gloves
Goggles, mask and sterile gloves
Mask, gown and a cap
Mask, sterile, gloves and a cap
Use grab bars in the bath tub or shower
Remove scatter rugs in the home
Keep all pets out of the house
Use soft-soled slippers when walking with the crutches.
Walk up behind the client and gently put a hand on the client’s shoulder while speaking
Speak to the client at the entrance of the room to avoid any episodes of violence
Speak and move slowly to the client while assessing the client’s needs
Wait until the client’s agitation has subsided before approaching the client.
Carefully pick-up the syringe from the floor and gently recap the needle
Carefully pick up the syringe in the floor and dispose it in sharps container
Obtain a dust pan and mop to sweep up the syringe
Call the housekeeping department to pick up the syringe
Puts all four points of the walker flat on the floor, puts weight on the hand pieces and then walks into it.
Put weight on the hand pieces, moves the walker forward and then walks to it
Puts weight on the hand pieces, slides the walker forward and then walks unto it
Walks into the walker, puts weight into the hand pieces, and then puts all four points of the walker on the flat floor
The client is able to rest axillae on the axillary bars
The nurse is able to place two fingers comfortably between the axillae and the axillary bars
The client is able to maintain the arms in a straight position when standing with the crutches
The nurse is able to place four fingers comfortable between the axillae and axillary bars
Cleanses using warm tap water and a bulb syringe
Intermittently exposes the wound to air.
Provides perineal care after each voiding and bowel movement (BM)
Provides prescribed sitz baths after the sutures are removed
Assist the client to move quickly from the lying position to the sitting position
Assess the client for signs of dizziness and hypotension
Elevate the head of the bed quickly to assist the client to a sitting position.
Allow the client to rise from the bed to standing position unassisted
Immediately inflates the balloon
Withdraws the catheter approximately 1 inch and inflates the balloon
Inserts the catheter until resistance is met and inflates the balloon
Inserts the catheter 2.5 to 5 cm and inflates the balloon
Giving the client mouthwash
Checking to see that the sputum basin is clean
Sending the sputum specimen to the laboratory immediately
Providing tissues for the expectoration
Enteric precautions should be instituted for the client.
Contact isolation should be initiated, since the disease is highly contagious
Universal precautions are quite sufficient, since the disease is transmitted sexually
Gloves and mask should be used when in the clients room.
Ensure that the family has signed the informed consent
Ensure that the client has signed the informed consent
Inform the family about the advance directive process
Inform the family about the process of a living will
Apply a mask to the client
Apply a mask and gown to the client
Apply a mask, gown, and gloves to the client
Notify the x-ray department so that the personnel can be sure to wear mask when the client arrives.
Eye wear (goggles)
Recaps the needle
Removes the gloves
Washes the hands
Places the syringe in the puncture resistant needle box container
Leave the client’s door open so that client can be monitored and answer the phone call
Finish the bath before answering the phone
Immediately walk out of the client’s room and answer the phone call
Cover the client, place the call light within reach, and the answer the phone call
To prevent falls
To restrict movement of a limb
To prevent the client from pulling out IV lines and catheters
To prevent the violent client from injuring self and others
Obtaining the specimen from the urinary drainage bag
Clamping the tubing on the drainage bag.
Aspirating a sample from the port on the drainage bag.
Wiping the port with an alcohol swab before inserting the syringe
Uses soap and water to cleanse the perineal area
Keep the drainage bag above the level of the bladder
Loops the tubing under the client’s leg
Lets the drainage tubing rest under the leg.
Side rails in the up position
Use of the night-light in hospital and bathroom.
Call bell placed within the client’s reach
Delays in responding to the call via the intercom that someone will attend to his or her needs.
Apply the restraint anyway
Contact the physician
Medicate the client with a sedative then apply the restraint
Compromise with the client and use wrist restraints
I realize that I should check the oxygen level of portable tank on a consistent basis.
I will keep my scented candles within 5 feet of my oxygen tank.
I will not sit in front of my wood burning fireplace with my oxygen on.
I will call the physician if I experienced any shortness of breath.
Use the plug anyway
Tape the electrical cord from the IV pump to the floor before plugging it in
Run the electrical cord from the IV pump under the carpet before plugging it in
Obtain a three-prong grounded plug adapter
Skid-resistant small area rugs in the living room
Clothes hamper at the end of the hallway
Area rugs on the stairs
Carpeted stairs secured with carpet tacks
Restrain the client until the physician can be reached
Call security to block all exit areas
Tell the client that he can not return to this hospital again if he leaves now
Call the nursing supervisor.
None, because the discussion took place in a quiet secluded area
They can be charged with slander
They can be charged with libel
None, because the physical therapist is involved in the client’s care
Refuse to go to the ICU
Go to the ICU, and tell the charge nurse he or she is ill and needs to go home
Call the hospital lawyer
Go to the ICU and inform the charge nurse of those tasks that cannot be performed
Request that the LPN review the materials from the inservice before performing the procedure.
Request that the LPN review the procedure in the hospital manual and to bring the written procedure into the client’s room for guidance during the procedure
Request that another LPN observe the procedure when it is performed
Perform the procedure with the LPN
Administer the additional 0.100 mg
Tell the client that the dose administered was not the total amount and administer the additional dose.
Tell the client that too much medication was administered and an error was made.
Complete an incident report
Near the client's right leg
Next to either leg
As space in the room permits
Near the client's left leg
Allergy to penicillin - type antibiotics
Age of 38 years
Hepatitis B infection
Negative rapid plasma reading ( RPR ) laboratory result
Urine output 45 mL / hr
Capillary refill 5 seconds
Serum pH 7.32
Blood pressure 90 / 48 mm Hg
Administering IV fluids
Assessing lung sounds
Performing range of motion exercises to extremities
Cut clothing along seams, avoiding bullet holes.
Initiate a chain of custody log
Place personal belongings in a labeled, sealed paper bag
Give clothing and wallet to the family.
Bright red bleeding from a neck wound
Penetrating abdominal injury
Open massive head injury in deep coma