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Guarantee
1. Describe how the concept of assault applies to the scenario where an AP
threatens a client regarding their use of a urinal.
The AP's actions are considered battery since they involve physical
contact.
The AP is invading the client's privacy by discussing their toileting
habits.
The AP's threat to put a diaper on the client constitutes assault
because it involves a threat of harm.
The AP is guilty of false imprisonment for restricting the client's
freedom.
2. The nurse allows the delegate to clarify without fear of repercussion. Which
of the following five rights of delegation is being demonstrated?
Right supervision/evaluation
Right direction/communication
Right circumstance
Right task
Right person
3. Why is it important for a client to understand advance directives before
surgery?
Advance directives are only necessary for elderly patients.
They are used to expedite the surgical process.
, Understanding advance directives ensures that the client's wishes
are respected in critical situations.
They allow family members to make decisions without consent.
4. A charge nurse is working in a busy post op unit making shift assignments.
Which of the following is an appropriate assignment for an LPN?
a patient who had an appendectomy requesting assistance with a bed
bath
a newly admit PT who had abdominal surgery that morning
a patient with urinary retention with an order for straight cath
a patient with a mastectomy needing d/c instructions
5. Why is it important to include scheduled procedures, such as a bone scan, in
the change-of-shift report?
Scheduled procedures can be communicated verbally at a later time.
Scheduled procedures are not relevant to the change-of-shift report.
The change-of-shift report should only focus on past events.
Including scheduled procedures ensures continuity of care and
prepares the incoming nurse for the client's needs.
6. Which of the following statements made by a client should indicate to the
nurse an understanding of advance directives?
"I plan to write that I don't want them to keep me on a breathing
machine."
"I know they won't go ahead with the surgery unless I prepare these
forms."
, "I will get my regular doctor to approve my plan before I hand it in at
the hospital."
"I'd rather have my brother make decisions for me, but I know it has to
be my life."
7. If the AP reports that the client is experiencing increased pain during
ambulation, what should the nurse's immediate action be based on the
delegation information provided?
Instruct the AP to continue ambulation regardless of the pain.
Ask the AP to document the pain in the client's chart.
Notify the physician immediately without assessing the client.
Assess the client's pain level and determine if further intervention is
needed.
8. *Mrs. Thompson tells her nurse that she fell in the shower. According to the
guidelines for documentation how should, this information be charted?*
Patient appears to have fallen in the shower.
Patient has a bruise on her left leg after falling in the shower
Patient states "fell in the shower"
Patient fell in the shower
9. A patient returned five hours ago from an inguinal hernia repair under
epidural anesthesia. Which piece of information would be most important for
the nurse to include in a change-of-shift report?
"He rates his pain intensity at 5 on a pain scale of 1-10."
"His abdomen is nondistended with hypoactive bowel sounds."
"The dressing over the surgical site is intact, clean and dry."
, "He has not voided since he returned from surgery."
10. Which of the following client's needs should the nurse assign to an assistive
personnel?
Updating the plan of care of a client who is post-op
Reapplying a condom catheter for a client who has urinary
incontinence
Applying a sterile dressing to a pressure ulcer
Reinforce teaching with a client who is learning to walk using a quad
cane
11. Who is the most appropriate staff member to assign to a client awaiting
transfer from the PACU after thoracic surgery?
AP
RN
LPN
Charge nurse
12. A nurse is caring for a patient who is becoming restless and slightly
confused and is trying to get out of bed without assistance. The nurse is
afraid the patient may fall and injure themselves, so she immediately places
the patient in restraints and raises all four side rails. From this action, the
nurse may be brought into a court of law for which of the following?
False imprisonment
Invasion of privacy
Assault
Battery