Leadership & Case management NCLEX style (Level 3) New Update 2023

Leadership & Case management NCLEX style (Level 3) New Update 2023 The acute care nurse is caring for a client with an infection. Which nursing action would be considered negligent? A. Not administering the client's prescribed dose of antibiotic medication B. Taking a picture of the client's stage II ulcer located on the sacrum C. Keeping the portable oxygen on while the client smokes at a designated area D. Talking about a client's condition to another nurse in the elevator - CORRECT ANSWER C --> Negligence is considered conduct that deviates from what a reasonable person would do in a particular circumstance. The nurse must take measures to protect the client if imminent danger or harm is evident. Not administering a prescribed antibiotic may be warranted if the client is allergic to the medication or has experienced an adverse effect from the drug. Options II and IV are examples of violating the client's privacy and confidentiality but are not considered negligent actions. A client is scheduled to have surgery, and has signed the consent form, but refuses to have a Foley catheter placed, saying, "That's not part of the surgery." How should the nurse respond to this situation? A. Explain that this step is part of the surgical prep and continue with the procedure. B. Explain that the client has already signed the consent and place the catheter. C. Respect the client's wishes, notify the physician, and document accordingly. D. Notify the charge nurse but do not document the client's wishes. - CORRECT ANSWER C --> Consent is required before procedures are performed. Depending on the invasiveness of the procedure, a written consent may be required. The client signed a consent form for surgery, and the refusal for placement of a catheter should be respected because it is the client's right to refuse. The nurse should document the incident and not continue with the procedure. Battery exists when there is not consent, even if the client was not asked. In this case, the client has the right to refuse other treatment surrounding pre- and postoperative care. A nurse is caring for an older adult client in the emergency department (ED) who was brought in by an adult child for vague flulike symptoms. While helping the client change into a gown, the nurse notices numerous bruises on the client's back and arms. When questioned, the client is distracted and ambiguous with answers. The nurse should prioritize which action? A. Report the situation to law enforcement. B. Report the required information through the administrative chain of the institution. C. Question the adult child who brought the client to the ED. D. File a written report in the client's chart. - CORRECT ANSWER B --> Nurses are considered mandatory reporters. Reporting of abuse or suspected abuse of vulnerable individuals is mandated in most states. As a general rule, the nurse reports the required information through the administrative chain of the institution, beginning with the nurse's immediate supervisor and the primary healthcare provider.