Call the supervisor and report Angelina.
Confront Angelina, saying that she feels she is intoxicated, and relieve her of her nursing duties immediately.
Ignore the situation.
Give Angelina a lecture about substance abuse and do nothing else.
To observe the type and amount of nasogastric tube drainage
Monitor the client for nausea or other complications
Irrigate the nasogastric tube with the ordered irrigant
Perform nostril and mouth care
A referral is needed to the psychiatrist who is to provide the client with answers
The client has a right to know about the prescribed medications
Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
"I am sorry. Referral information can only be provided by the client’s providers"
"I can never give any information out by telephone. How do I know who you are?"
"Since this is a referral, I can give you this information"
"I need to get the client’s written consent before I release any information to you"
"I must document and report any important information."
"I can’t make such a promise."
"That depends on what you tell me."
"I must report everything to the treatment team."
Dopamine drip IV with vital signs monitored every 5 minutes
A myocardial infarction that is free from pain and dysrhythmias
A tracheotomy of 24 hours in some respiratory distress
A pacemaker inserted this morning with intermittent capture
Focus on reality orientation to place and person
Assist with the report of the client’s complaint to the police
Obtain more details of the client’s claim of abuse
Document the statement on the client’s chart with a report to the manager
Ask to not be assigned to this client or to work on another unit
Tell the client that such behavior is inappropriate
Inform the client that hospital policy prohibits staff to date clients
Discuss the boundaries of the therapeutic relationship with the client
Keep the client’s room door cracked to minimize the distractions
Assign 1 of the nursing staff to visit the client regularly
Eassure the client that 1 staff person will check frequently if the client needs anything
Arrange for each staff member to go into the client’s room to check on needs every hour on the hour
Assign an RN to provide total care of the client
Assign a nursing assistant to help the client with self-care activities
Delegate complete care to an unlicensed assistive personnel
Supervise a nursing assistant for skin care
To give him the chart as requested.
Not to allow him to read the chart.
To ask the attending surgeon if it is permissible for him to read the chart.
To ask the client if she wants him to read her chart.
Normal patterns of behavior may be labeled as deviant, immoral, or insane
The meaning of the client’s behavior can be derived from conventional wisdom
Personal values will guide the interaction between persons from 2 cultures
The nurse should rely on her knowledge of different developmental mental stages
Since the client came to the hospital consent is implied even if the consent for the surgery has not been signed.
All invasive procedures require a consent form.
The nurse should have him sign a consent form immediately
The nurse should have the next of kin sign the necessary consent form
Notify the physician and document in the nurse’s notes that the physician was notified of the error.
Notify the supervisor, complete a medication error incident report, and document in the nurse’s notes that an incident report was completed
Notify the house supervisor, assess client carefully, and document only if adverse or untoward effects occur.
Notify the physician, complete an incident report, and document the notification of the physician and any assessments made.
Arrange for a volunteer to stay with the client during the day to provide for socialization needs and to facilitate communication with staff.
Explain to the family that consistency in enforcing rules is important to prevent complaints from the families of other clients.
Suggest that the family visit in shifts during the normal visiting hours, since the client needs to sleep at night.
Make an exception to visiting regulations because of the long-term nature of the client’s recovery and the need for family support.
The principle of justice prohibits giving one client a privilege that other clients are not permitted.
Faith healers do not meet the standards for clergy exemption from visitation rules
Medicine men are not approved by the hospital as legitimate health care providers.
Provision of holistic care requires that the client’s belief system is honored
Asking the client if she is Mrs. Jefferson.
Reading the client’s identification bracelet
Reading the client’s medical record.
Asking the roommate to state the client’s name.
"He has a lot of problems. You need to be patient with him."
"I will talk with him and try to figure out what to do."
"He is scared and taking it out on you. Let’s try to figure out what to do."
"Ignore him and get the rest of your work done. Someone else can take care of him tomorrow."
Minimize further contact with the client
Tell the client that his/her behavior is inappropriate
Tell the client that hospital policy prohibits dating clients
Discuss the boundaries of the relationship with the client
Observe a client’s self-administration of insulin
Cleanse and dress a small decubitus ulcer
Monitor a client’s response to physical therapy
Apply and care for a client’s rectal pouch