Nursing Elites

1. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:

• A. the client reports no episodes of awakening during the night.
• B. the client falls asleep within 1 hour of going to bed.
• C. the client reports satisfaction with their amount of sleep.
• D. the client rates sleep as an 8 or more on the visual analog scale.

Correct answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

2. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?

• A. Notify the physician.
• B. Clamp the chest tube.
• C. Replace the system.
• D. Document the finding

Correct answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

3. When should the biohazard emblem be affixed to containers according to the orientation nurse educator reviewing the biohazard legend with a class of new employees?

• A. when there is presence of blood and body fluids.
• B. when there is the need for droplet precautions.
• C. when there is contact isolation.
• D. when there is the potential for airborne transmission.

Correct answer: A

Rationale: The correct answer is 'when there is presence of blood and body fluids.' When handling body substances like blood and body fluids, the risk of transmission of infections increases. Federal regulations mandate warning labels on containers to alert employees and waste collectors. The biohazard emblem consists of a three-ring symbol overlaying a central concentric ring. Blood, wound drainage, feces, and urine are examples of body fluids that can transmit infections and diseases to others. The other choices, B, C, and D, are incorrect because the presence of the biohazard emblem is specifically linked to the handling of blood and body fluids, not to droplet precautions, contact isolation, or airborne transmission.

4. A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by undertaking which action?

• A. Reassuring the client that the risks are minimal
• B. Noting in the client's record that the client was not told about the risks of the surgery
• C. Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room
• D. Informing the surgeon verbally about the lack of information provided to the client

Correct answer: B

Rationale: A nurse serves as a client advocate by protecting the client's right to be informed and to participate in decisions regarding care. In this scenario, the nurse should document in the client's record that the client was not informed about the risks of the surgery. This action ensures that the issue is officially noted and can be addressed by the healthcare team. Reassuring the client that the risks are minimal is incorrect because it dismisses the client's concerns and does not address the lack of information provided. Writing a note on the client's chart to inform the surgeon is not as effective as ensuring that the issue is officially documented in the client's record, where it can be reviewed and addressed by the healthcare team. Informing the surgeon verbally is not as reliable as documenting the concern in the client's record, which provides a formal and lasting record for review and follow-up.

5. A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?

• A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
• B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
• C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
• D. Negligence, as the nurse ignored the client's right to choose regarding his healthcare.

Correct answer: A

Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation. The other options are incorrect: - Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions. - Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving. - Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.

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