Choice A rationale:

Asking a patient if their neighbor can visit is not a violation of HIPAA policy as it does not involve sharing sensitive patient information.

Choice B rationale:

Using the facility computer to document patient care is appropriate and not a violation of HIPAA policy, assuming the nurse is following proper security protocols.

Choice C rationale:

Looking at a neighbor's chart to add them to a prayer list at church is a clear violation of HIPAA policy. This action breaches patient confidentiality and compromises their privacy, which is essential under HIPAA regulations.

Choice D rationale:

Failing to log off the computer charting system after documenting patient care is also a violation of HIPAA policy. This can lead to unauthorized access and potential misuse of patient information, putting patient privacy at risk.

Choice E rationale:

Discussing a patient with a coworker in a public place like an elevator violates HIPAA policy. Even though the conversation is with a colleague, it is essential to protect patient information in all circumstances to maintain confidentiality and trust.

Choice A rationale:

Avoiding assisting a restless patient to walk does not address the issue of patient confusion and the risk of falling. Restless patients might need assistance, and refusing to help them walk could lead to further complications or falls.

Choice B rationale:

Discouraging the family from staying with the patient does not promote patient safety. Family members can provide additional support and supervision, reducing the risk of falls for a confused patient.

Choice C rationale:

Moving the patient farther away from the nurses' station does not address the patient's confusion or the risk of falling. It might even increase the response time in case of an emergency.

Choice D rationale:

Asking the family about the patient's preferences for movies or music and offering these activities is an appropriate way to engage the patient without resorting to restraints. Providing stimulating and enjoyable activities can help distract and calm the patient, reducing restlessness and the risk of falls.

Choice A rationale:

The statement that abbreviations are forbidden on a medical record is not entirely accurate. While there are specific abbreviations that should be avoided, not all abbreviations are forbidden. The key is to use recognized and standard abbreviations to prevent misunderstandings.

Choice B rationale:

The statement about using abbreviations only for units of measurement is too restrictive. Abbreviations can be used for various purposes in medical charting, but it is crucial to ensure they are standard, recognized, and widely understood to maintain clarity and patient safety.

Choice C rationale:

Uncommon and unrecognized abbreviations could indeed be misunderstood, leading to misinterpretation of important information. This misunderstanding could compromise patient safety by affecting treatment decisions or medication administration. Using standardized and commonly accepted abbreviations ensures clear communication among healthcare professionals.

Choice D rationale:

Allowing the use of uncommon and unrecognized abbreviations with staff education does not guarantee patient safety. Educating staff about these abbreviations might mitigate some risks, but misunderstandings can still occur, especially in high-stress situations or when dealing with staff turnover. Standardized communication methods are essential to prevent errors.

Choice A rationale:

In the SBAR method, "S" stands for Situation. This portion of the report includes a brief and concise statement about the patient's current situation or problem. In this case, option A provides a clear and specific statement about the patient's situation, indicating that Mr. Jones is being transferred to another unit from the emergency room. The nurse would identify this statement as the "situation" portion of the SBAR report because it conveys the current status of the patient and the reason for the communication.

Choice B rationale:

Option B discusses the patient's symptoms and condition in detail, focusing on the left knee swelling, bruising, redness, and tenderness. While this information is important, it falls under the "Background" section of the SBAR report, not the "Situation" section. The "Situation" section should provide a brief overview of the patient's current status and the reason for the communication, which choice A accurately conveys.

Choice C rationale:

Option C mentions the patient's request for a specific bed location, which is relevant to the patient's preferences but does not constitute the "situation" portion of the SBAR report. This information is more appropriate for the "Recommendation" or "Request" section of the SBAR communication model.

Choice D rationale:

Option D provides information about the patient's history of left knee pain following a motor vehicle accident four days ago. While this information is important for understanding the patient's background, it does not represent the current situation or reason for the communication. Therefore, it does not fit the "situation" portion of the SBAR report.

Choice A rationale:

In the SOAP format used for medical documentation, "P" stands for Plan. The "P" portion of the note includes the healthcare provider's plan for the patient, which may involve treatments, medications, or other interventions. Option A discusses the patient's ability to walk unassisted, feelings of safety while ambulating, and plans for discharge home in 3 days. This information represents the provider's plan for the patient's care and fits the "P" portion of the SOAP note.

Choice B rationale:

Option B describes the patient's physical examination findings related to range of motion and reflexes in the lower extremities. This information falls under the "Objective" section of the SOAP note, which includes observable and measurable data. While important for the overall patient assessment, it does not represent the provider's plan for the patient's care (the "P" portion of SOAP).

Choice B rationale:

Isometric exercises involve contracting muscles without changing the length of the muscle or joint angle. In this case, squeezing the gluteal muscles tightly constitutes an isometric exercise. Isometric exercises are often used in rehabilitation settings to strengthen specific muscle groups without putting too much strain on the joints.

Choice A rationale:

Option A describes a range of motion exercise involving the wrist, which is not an isometric exercise. Isometric exercises focus on static muscle contractions, not dynamic movements like circular motions.

Choice C rationale:

Lifting a 5-pound weight to increase arm strength involves isotonic exercise, not isometric exercise. Isotonic exercises involve muscle contractions with movement and changing muscle length, unlike isometric exercises, where muscle length remains constant.

Choice D rationale:

Bending the knee up to the chest is an example of a range of motion exercise and does not constitute an isometric exercise. Range of motion exercises involve moving joints through their full extent, but isometric exercises involve static muscle contractions without joint movement.

Choice A rationale:

Administering the medication at 0500, 1300, and 2100 means the medication will be given during the day shift and evening shift, not during the 11:00 pm–7:30 am shift.

Choice B rationale:

Administering the medication at 0500, 1300, and 2100 means the medication will be given during the day shift and evening shift, not during the 11:00 pm–7:30 am shift.

Choice C rationale:

Administering the medication at 0500 falls within the 11:00 pm–7:30 am shift. However, the medication will not be given again during this shift because the next scheduled administration is at 1300, which is beyond the 7:30 am end time of the shift.

Choice D rationale:

Administering the medication at 2100 is within the 11:00 pm–7:30 am shift. However, the medication was already given at 0500, and the next scheduled administration is at 1300, which is beyond the 7:30 am end time of the shift.

Choice A rationale:

Calling the physician to request an antianxiety medication might address the client's anxiety, but it does not directly respond to the client's existential question about God punishing them.

Choice B rationale:

Sharing personal religious beliefs with the client can be inappropriate and may not align with the client's beliefs, potentially causing discomfort or offense.

Choice C rationale:

Sitting quietly with the client and offering caring touch demonstrates empathy, compassion, and presence. It allows the nurse to provide emotional support without imposing personal beliefs or judgments. This approach encourages the client to express their feelings and facilitates a therapeutic nurse-client relationship.

Choice D rationale:

Advising the client about a good worship center nearby does not directly address the client's existential question or provide emotional support. Additionally, the client may not be interested in religious activities at this moment.

Choice A rationale:

Telling the patient that their wife will be fine does not address the patient's concerns and may come across as dismissive. It does not encourage further communication about the patient's fears and worries.

Choice B rationale:

Dismissing the patient's concerns and instructing them to sleep does not address the underlying issue. It fails to acknowledge the patient's emotional distress and may make the patient feel unheard and unsupported.

Choice C rationale:

Offering medication without exploring the patient's concerns further does not address the root cause of the patient's anxiety. It is important to assess the patient's emotional state and concerns before resorting to medication.

Choice D rationale:

Asking the patient, "What seems to be concerning you the most?" demonstrates active listening and empathy. It encourages the patient to express their feelings and fears, allowing the nurse to provide appropriate emotional support and interventions. Open-ended questions like this facilitate therapeutic communication and help establish trust between the nurse and the patient.

Choice A rationale:

Making sure the consent is signed and in the patient's chart in a timely manner is an important step in the consent process. However, the most appropriate action for the nurse in this situation is to verify the necessity of the surgical procedure before placing the consent in the chart. This is crucial to ensure that the patient fully understands the procedure they are consenting to and that it is medically necessary. Verifying the necessity of the surgical procedure helps in preventing unnecessary procedures, promoting patient safety, and adhering to ethical principles.

Choice B rationale:

Verifying the necessity of the surgical procedure before placing the consent in the chart is the most appropriate action for the newly licensed nurse. This step ensures that the procedure is medically necessary, aligns with the patient's condition, and promotes informed decision-making. By confirming the necessity, the nurse upholds the principle of beneficence, ensuring the patient's well-being, and autonomy, allowing the patient to make informed decisions about their healthcare.

Choice C rationale:

Asking a family member to translate the consent into the language the patient understands might be helpful in improving the patient's understanding of the procedure. However, the primary concern in this situation is verifying the necessity of the surgical procedure. While communication is essential, it does not address the core issue of confirming the medical need for the surgery.

Choice D rationale:

Explaining the risks and benefits of the surgical procedure prior to getting a signature is a vital step in the consent process. However, the question specifically asks for the most appropriate action, which is to verify the necessity of the procedure. Explaining the risks and benefits is an important follow-up step after ensuring the procedure's necessity.

Choice A rationale:

"I'm sorry, I didn't hear what you said about your job. Please tell me again.”. This response demonstrates active listening and empathy. It acknowledges the patient's feelings and encourages them to share their concerns, promoting therapeutic communication. By asking the patient to repeat what they said, the nurse shows genuine interest in understanding the patient's emotions and concerns, fostering trust and rapport.

Choice B rationale:

"Why are you crying so hard about your job? What happened to your job?" This response, while well-intentioned, may come across as intrusive and judgmental. It does not encourage open communication and may make the patient feel defensive, hindering the nurse-patient relationship.

Choice C rationale:

"It's natural to be worried about your job. We all worry about our jobs sometimes.”. While this response acknowledges the patient's feelings, it does not address the specific concern the patient mentioned. It generalizes the situation and does not invite the patient to share more about their feelings, missing an opportunity for deeper communication and understanding.

Choice D rationale:

"Your job must be important to you since you are talking about it.”. This response makes an assumption about the importance of the patient's job without allowing the patient to express their feelings. It does not demonstrate active listening or empathy and may not encourage the patient to open up further about their concerns.

Choice A rationale:

The nurse verifies the recipient's fax number before faxing private patient information. This action is appropriate and ensures that patient information is sent to the correct recipient, maintaining patient confidentiality and privacy. Verifying recipient information is a standard practice in healthcare settings to prevent data breaches.

Choice B rationale:

The nurse documents the patient assessment using objective data. This action is appropriate and follows evidence-based practice guidelines. Objective data are measurable and observable, providing a clear picture of the patient's condition. Objective documentation enhances communication among healthcare providers and ensures accurate representation of the patient's status.

Choice C rationale:

The nurse posts the obituary of a patient on social media. This action is highly inappropriate and unethical. It breaches patient confidentiality and privacy, violating the Health Insurance Portability and Accountability Act (HIPAA) regulations. Sharing patient information, especially sensitive details like an obituary, on social media platforms is a serious violation of privacy and can lead to legal consequences.

Choice D rationale:

The nurse discards copies of patient information into the regular trash bin. This action is inappropriate and violates patient confidentiality. Proper disposal of patient information is crucial to protect patient privacy and comply with regulations. Patient documents should be shredded or disposed of in designated secure bins to prevent unauthorized access to sensitive information.

Choice E rationale:

The nurse accesses the nurse's own health record via computer. This action is inappropriate unless there is a legitimate reason related to patient care. Accessing one's own health record without a valid purpose is a breach of patient privacy and can lead to disciplinary actions. Healthcare professionals should only access patient records when necessary for providing care and treatment.

Choice A rationale:

Providing non-slip footwear to patients during their stay is a good preventive measure, but it only addresses the risk of falls related to slippery floors. It does not address the overall fall risk, especially for elderly patients who may need constant supervision and assistance.

Choice B rationale:

Keeping the bed in a high position for ease of care might seem practical, but it increases the risk of falls when the patient attempts to get out of bed. Lowering the bed reduces the risk of injury if a fall occurs and is a more appropriate intervention.

Choice C rationale:

Instituting a policy requiring a sitter for all patients above the age of 60 is the best option among the choices provided. Elderly patients are at a higher risk of falls due to various factors such as weakened muscles, balance issues, and medication side effects. Having a dedicated sitter ensures constant supervision, timely assistance, and prompt intervention if the patient attempts to get out of bed, significantly reducing the risk of falls.

Choice D rationale:

Avoiding the use of a night light in the room to promote sleep is not a recommended intervention. While promoting sleep is essential for overall patient well-being, patient safety should always be the priority. Providing adequate lighting, especially at night, reduces the risk of falls and other accidents.

Choice A rationale:

Weight-bearing activities are not suitable for a patient with contractures, as they may worsen joint stiffness and discomfort. Engaging in weight-bearing activities could lead to further limitations in joint mobility and exacerbate the contractures.

Choice B rationale:

Exercises to strengthen flexor muscles might be beneficial in other contexts, but for a patient with contractures, the focus should be on improving joint mobility and preventing the contractures from worsening. Strengthening exercises do not directly address the issue of limited joint mobility caused by contractures.

Choice C rationale:

Range of motion exercises are essential for patients with contractures. These exercises involve moving joints through their full range of motion to maintain or improve joint flexibility. Regularly performing range of motion exercises prevents further tightening of muscles and joints, thereby preventing the worsening of contractures.

Choice D rationale:

Frequent position changes are important to prevent pressure ulcers and maintain overall comfort, but they do not specifically address the issue of contractures. While position changes are necessary, they are not the primary intervention for managing contractures.

Choice A rationale:

Applying ankle restraints but leaving the wrists unrestrained is not a balanced approach. Restraints should only be used when necessary and should be applied correctly following the healthcare facility's policies and guidelines. Applying restraints to one part of the body while leaving another unrestrained can lead to injuries and is not a safe practice.

Choice B rationale:

Tying a double knot that is difficult to undo can be dangerous in emergency situations. Restraints should allow for quick release in case of emergencies, ensuring patient safety. Difficult-to-undo knots can delay the removal of restraints, leading to potential harm to the patient.

Choice C rationale:

Tying a slip knot to the side rails of the bed is unsafe and against restraint protocols. Slip knots can tighten when pulled, increasing the risk of injury to the patient. Restraints should be applied to designated areas and never tied to movable parts of the bed or other objects in the room.

Choice D rationale:

Checking on the patient frequently is the most appropriate action when a patient is in restraints. Regular monitoring ensures the patient's safety and well-being, assesses their comfort, and allows for prompt response to any signs of distress or discomfort. Frequent checks also help in preventing complications associated with immobilization, such as pressure ulcers and impaired circulation.

Choice A rationale:

Statements provided by the patient's family are not a reliable defense against nursing negligence. While family statements can offer context, they may not always be accurate or objective. Legal defenses require concrete evidence and accurate documentation.

Choice B rationale:

Accurate documentation by the nurse is the best defense against allegations of nursing negligence. Thorough and precise documentation provides a clear account of the patient's condition, the care provided, and the patient's response. Proper documentation is essential for legal and ethical reasons and serves as a valuable defense in case of legal disputes.

Choice C rationale:

Testimony of other nurses may support the case but may not be as reliable as accurate documentation. Nurse testimony can be subjective and may vary, making it less robust as a defense compared to comprehensive and detailed documentation.

Choice D rationale:

Inclusion of expert witnesses can be helpful, but their testimony is most effective when combined with accurate documentation. Expert witnesses can provide specialized knowledge and opinions, but their credibility is enhanced when supported by thorough and precise nursing documentation.

Choice A rationale:

Electronic medical records being available even during a power outage is a significant advantage. This ensures healthcare providers can access critical patient information, which is essential for patient safety and continuity of care, especially during emergencies.

Choice B rationale:

Timely documentation is facilitated by electronic charting, as it eliminates the delays associated with manual paperwork. Healthcare providers can input data efficiently, reducing the risk of errors and ensuring that the patient's information is up-to-date.

Choice C rationale:

The patient's electronic medical record being available to all members of the healthcare team simultaneously promotes collaborative and coordinated care. This real-time access enables healthcare professionals to make informed decisions based on the most recent patient data, leading to improved patient outcomes.

Choice D rationale:

Continuous updates in the electronic medical record system enhance continuity of care. The ability to access the most recent information ensures that all healthcare providers are aware of the patient's current status, ongoing treatments, and any changes in their condition. This knowledge is vital for delivering safe and effective care.

Choice A rationale:

Permitting smoking in the home, even with low-flow oxygen, is highly dangerous and increases the risk of fire. Oxygen supports combustion, and any open flames, including smoking materials, can lead to a catastrophic fire. Therefore, this option is incorrect and unsafe.

Choice B rationale:

Placing the oxygen tank in direct sunlight is not advisable. Oxygen tanks should be stored in cool, well-ventilated areas away from direct sunlight, heat sources, and flammable materials. Storing the tank in direct sunlight can increase the pressure inside the tank, potentially leading to leaks or ruptures.

Choice C rationale:

Encouraging the patient to use electric razors is a safe practice when wearing oxygen. Electric razors eliminate the risk of open flames, reducing the potential for accidents. This option promotes patient safety and is a suitable instruction for patients using oxygen at home.

Choice D rationale:

Not using electrical equipment near the oxygen administration set is crucial for patient safety. Electrical equipment can generate sparks, posing a significant fire hazard in the presence of oxygen. Instructing patients to keep electrical devices away from oxygen supplies helps prevent accidents and ensures a safe home environment for patients requiring oxygen therapy.

Choice A rationale:

When a nurse delegates a specific intervention to unlicensed assistive personnel (UAP), the nurse transfers the responsibility for completing the task to the UAP. However, the nurse remains accountable for the outcome. Delegation does not absolve the nurse of their accountability; instead, it means that the nurse trusts the UAP to perform the task safely and effectively under their supervision. This approach allows healthcare teams to work collaboratively, improving efficiency and patient care outcomes.

Choice B rationale:

Nurses do have the authority to delegate interventions to UAP, but they must do so responsibly and within the scope of practice. Improper delegation or delegating tasks that UAP are not trained to perform can lead to adverse outcomes and legal consequences.

Choice C rationale:

While the UAP is responsible for their own actions, the nurse remains accountable for the overall patient care. Nurses must ensure that tasks are delegated to competent individuals and provide adequate supervision and guidance. The nurse cannot completely transfer all responsibility to the UAP without being accountable for the outcome.

Choice C rationale:

In this situation, the nurse should continue to teach the patient about his medications despite his disinterest. It is essential for the patient to be knowledgeable about his own medications, as he will be responsible for taking them once discharged. While involving family members in the teaching process can be beneficial, the primary responsibility lies with the patient. Documenting the patient's request is also important for the record, but it does not replace the need for the patient to be informed about his medications.

Choice A rationale:

Reminding the patient of his responsibility is a good initial approach, but it should be followed by continued teaching to ensure the patient understands his medications thoroughly.

Choice B rationale:

Documenting the patient's request is important, but it does not address the patient's lack of interest in learning about his medications. The nurse should still provide education to the patient.

Choice D rationale:

Asking the patient why his wife knows about his medications is confrontational and may not be well-received by the patient. It does not address the primary issue, which is the patient's disinterest in learning about his medications.

Choice C rationale:

When a patient has been bedridden for an extended period, such as two weeks, the nurse expects to find atrophy of leg muscles due to immobility. Lack of physical activity leads to muscle wasting, which can result in decreased muscle mass and strength. This condition is reversible with proper rehabilitation and exercise.

Choice A rationale:

Decreased respiratory rate due to stronger lungs is not a typical effect of immobility. Immobility can lead to decreased lung expansion and increased risk of respiratory complications, such as pneumonia.

Choice B rationale:

Increased urinary output due to enhanced bladder muscle tone is not a direct effect of immobility. Immobility can affect urinary elimination, but it is more likely to cause urinary retention due to decreased mobility and inability to reach the bathroom independently.

Choice D rationale:

Frequent bowel movements due to increased peristalsis are not expected with immobility. Immobility often leads to slowed peristalsis, which can result in constipation rather than frequent bowel movements.

Choice A rationale:

Maintaining the patient in a supine position during rest would not be appropriate for a client with shortness of breath. This position can worsen breathing difficulties, especially in clients with respiratory issues. It reduces lung expansion and can lead to increased work of breathing.

Choice B rationale:

Monitoring the client's oxygen saturation hourly is the appropriate intervention for a client with shortness of breath. Oxygen saturation (SpO2) levels indicate the percentage of oxygen bound to hemoglobin in the blood. Monitoring SpO2 levels helps assess the client's oxygenation status and provides crucial information about the effectiveness of respiratory interventions. Normal oxygen saturation levels typically range between 95% to 100%. Monitoring allows timely recognition of hypoxemia, enabling prompt intervention to improve oxygenation and prevent complications.

Choice C rationale:

Ambulating the client in the hall four times daily may not be suitable for a client experiencing shortness of breath, as it can exacerbate respiratory distress. Ambulation increases oxygen demand and can further compromise oxygenation in individuals struggling to breathe.

Choice D rationale:

Encouraging high protein foods during mealtime is unrelated to the immediate management of shortness of breath. While proper nutrition is essential for overall health and healing, it does not directly address the acute issue of respiratory distress.

Choice A rationale:

The nurse mistakenly calling the patient's daughter "your wife" is a communication error but does not qualify as a sentinel event. Sentinel events are serious, largely preventable patient safety incidents that result in significant harm or death to the patient. Miscommunication, while important to address, does not fall under the category of a sentinel event.

Choice B rationale:

A surgical procedure performed on the wrong leg of a patient is a classic example of a sentinel event. Wrong-site surgery is a serious medical error that can lead to severe consequences for the patient. Proper protocols and procedures, such as time-outs and site marking, are in place to prevent such incidents, making this a sentinel event that requires immediate investigation and analysis to prevent recurrence.

Choice C rationale:

The surgical procedure being postponed by 30 minutes, while potentially inconvenient, does not constitute a sentinel event. Delays in surgical schedules are not uncommon due to various reasons such as emergencies or the complexity of preceding procedures. While delays should be minimized, they do not necessarily result in patient harm or death, making them different from sentinel events.

Choice D rationale:

The nurse failing to raise the bed to a working height during patient care is a safety concern but does not qualify as a sentinel event. It is important for nurses to adhere to proper body mechanics and safety protocols to prevent accidents and injuries. While this situation requires correction and education, it does not meet the criteria of a sentinel event.

Choice A rationale:

Moving the patient to the side of the bed is the first nursing action that should be implemented when assisting the patient to a lateral position for placement of a bedpan. This step ensures proper body mechanics and patient safety during the transfer. The nurse should assist the patient to the edge of the bed, farthest from them, and then help the patient turn onto their side, facing away from the nurse. This position facilitates the placement of the bedpan and maintains the patient's dignity and comfort.

Choice B rationale:

Placing the patient's arm over the chest is a subsequent step after moving the patient to the side of the bed. After the patient is in the lateral position, the nurse should assist in placing the uppermost arm comfortably over the chest to maintain balance and stability during the bedpan placement.

Choice C rationale:

Raising the bed to a proper working height is essential for the nurse's ergonomic safety and comfort during the procedure. However, it is not the first step in assisting the patient to a lateral position. The bed should be at a height that allows the nurse to work comfortably without straining their back, but this step comes after the patient has been safely positioned on their side.

Choice D rationale:

Turning the patient using the draw sheet is another appropriate technique for repositioning patients, especially when they are unable to assist with the movement. However, in this scenario, the nurse needs to assist the patient to a lateral position for the bedpan placement, which involves different techniques. Using a draw sheet might be necessary in other situations, such as when turning a bedridden patient in bed, but it is not the first action for placing a bedpan.

Choice A rationale:

The incident report is not a format for an audiotape report. Incident reports are written records used to document details of an unexpected event or accident, such as a patient fall, to analyze the causes and implement corrective measures.

Choice B rationale:

Incident reports are not primarily used as a basis for evaluating staff members and pay raises. They focus on patient safety and quality improvement, not employee performance evaluations.

Choice C rationale:

The primary purpose of an incident report is to identify risks and corrective measures. Incident reports are essential tools in healthcare facilities to track and analyze adverse events, identify patterns, and implement preventive measures to enhance patient safety. By documenting incidents and analyzing the data, healthcare organizations can identify potential risks and develop strategies to prevent similar occurrences in the future.

Choice D rationale:

While incident reports may be used as a basis for disciplinary actions in some cases, their main purpose is to improve patient safety. Disciplinary actions are taken after a thorough analysis of the incident report, which identifies areas for improvement and preventive measures.