Page 183 - Saunders Comprehensive Review For NCLEX-RN

Rationale: After a client’s fall, the nurse must frequently reassess the client,
because potential complications do not always appear immediately after the fall. The
client’s fall should be treated as private information and shared on a “need to know”
basis. Communication regarding the event should involve only the individuals
participating in the client’s care. An occurrence report is a problem-solving
document; however, its completion is not documented in the nurse’s notes. If the
nursing supervisor has been made aware of the occurrence, the supervisor will
contact the nurse if status update is necessary.
Test-Taking Strategy: Note the strategic word, next. Using the steps of the
nursing process will direct you to the correct option. Remember that assessment is
the first step. Additionally, use Maslow’s Hierarchy of Needs theory, recalling that
physiological needs are the priority. The correct option is the only option that
addresses a potential physiological need of the client.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Safety
Health Problem: N/A
Priority Concepts: Communication; Safety
References: Potter et al. (2017), pp. 312, 367.

19. Answer: 2

Rationale: Floating is an acceptable practice used by hospitals to solve
understaffing problems. Legally, the nurse cannot refuse to float unless a union
contract guarantees that nurses can work only in a specified area or the nurse can
prove the lack of knowledge for the performance of assigned tasks. When
encountering this situation, the nurse should set priorities and identify potential
areas of harm to the client. That is why clarifying the client assignment with the team
leader to ensure that it is a safe one is the best option. The nursing supervisor is
called if the nurse is expected to perform tasks that he or she cannot safely perform.
Submitting a written protest and calling the hospital lawyer is a premature action.
Test-Taking Strategy: Note the strategic word, best. Eliminate option 1 first
because of the word refuse. Next, eliminate options 3 and 4 because they are
premature actions.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Leadership/Management: Ethical/Legal
Health Problem: N/A
Priority Concepts: Care Coordination; Professionalism
Reference: Potter et al. (2017), p. 311.

20. Answer: 3

Rationale: Nurse practice acts require reporting impaired nurses. The board of
nursing has jurisdiction over the practice of nursing and may develop plans for

183