AND ANSWERS
A nurse is assisting with the care for a client on a medical surgical unit.
Exhibit 1
Nurses' Notes
1000:Client admitted to unit from the emergency department for a right hip fracture following a
fall. Leg is currently splinted and client is scheduled for surgery at 1400.1100:Provider met with
client to review informed consent.
Notify the nurse manager of the problem
Complete a facility incident report
A nurse is preparing to reinforce discharge teaching with a client who speaks a different
language than the nurse. The client has a new diagnosis of diabetes mellitus and their partner is
at the bedside. Which of the following actions should the nurse take?
Contact an interpreting service via telephone to assist with the instructions.
A nurse enters a client's room at the beginning of a shift. Which of the following findings
requires intervention by the nurse?
A capped bottle of sterile water that was opened 36 hr ago
, A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday
scheduling. Which of the following actions should the charge nurse take?
Encourage each staff nurse to give up something as part of the negotiation.
A nurse is assisting with the development of an in-service about the process of evidence-based
practice. Which of the following actions should the nurse include as the first step of this
process?
Question a current clinical practice that does not seem effective.
A nurse is assisting with the evacuation of clients who have been triaged following a mass
casualty event. Which of the following clients should the nurse recommend for first transport to
the health care facility?
A client who has paradoxical respirations and has been assigned a red tag
A nurse in a long-term care facility is caring for a client who has heart failure and is refusing to
take a new medication. Which of the following responses should the nurse make?
You have the right to refuse the medication."
A charge nurse is talking with two assistive personnel (AP) who are angry about the order in
which lunch breaks are scheduled on the unit. Which of the following statements by the charge
nurse demonstrates the use of compromise?
"You can take turns going to lunch first every other week."