A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?
Placing a client in restraints without having a healthcare provider’s order.
Administering the medication to a client behind a closed curtain.
Informing a client that the medication being administered is a vitamin.
Enlisting security personnel to assist with restraining the client.
The Correct Answer is A
Choice A rationale
Placing a client in restraints without having a healthcare provider’s order is a violation of patient rights and safety protocols. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety and well-being of the patient. Unauthorized use of restraints can lead to physical and psychological harm, and it is essential to follow established guidelines and obtain the necessary orders before applying restraints.
Choice B rationale
Administering the medication to a client behind a closed curtain is not a violation. This action ensures the client’s privacy and dignity during the administration of medication. Maintaining privacy is a standard practice in healthcare settings to respect the patient’s confidentiality and comfort.
Choice C rationale
Informing a client that the medication being administered is a vitamin is a violation of ethical and legal standards. It is essential to provide accurate information to the patient about the medication being administered. Misleading the patient can undermine trust and lead to potential harm if the patient has allergies or contraindications to the medication.
Choice D rationale
Enlisting security personnel to assist with restraining the client is not a violation if done appropriately. In situations where the client poses a danger to themselves or others, it may be necessary to involve security personnel to ensure safety. However, this should be done following proper protocols and with the necessary orders in place.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A rationale
Eschar and slough are indicative of necrotic tissue and are not signs of proper healing. Eschar is a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite or other insect. Slough is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation. Both eschar and slough need to be removed for proper wound healing to occur.
Choice B rationale
Erythema and serosanguineous exudate can be present in the early stages of wound healing, but one week post-surgery, these signs may indicate inflammation or infection rather than proper healing. Erythema is redness of the skin caused by increased blood flow to the capillaries, often a sign of infection or irritation. Serosanguineous exudate is a thin, watery fluid that is slightly pink due to the presence of small amounts of blood, which can be normal immediately after surgery but should decrease over time.
Choice C rationale
A well-approximated incision site is a sign of proper healing. This means that the edges of the wound are close together and aligned, which promotes faster and more efficient healing. Proper approximation of the wound edges reduces the risk of infection and promotes the formation of a strong, healthy scar.
Choice D rationale
Beefy red granulation tissue is a sign of healing in open wounds, not in surgical incisions that are closed. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It is typically bright red or pink and indicates that the wound is healing from the inside out. However, in a surgical incision that is healing properly, the wound edges should be well approximated, and granulation tissue should not be visible.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.
Choice B rationale
Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.
Choice C rationale
Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.
Choice D rationale
Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.
Choice E rationale
Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.