Page 2604 - Saunders Comprehensive Review For NCLEX-RN

Reference: Lewis et al. (2017), p. 26.

910. Answer: 1

Rationale: Assault occurs when a person puts another person in fear of harmful or
offensive contact and the victim fears and believes that harm will result from the
threat. In this situation, the nurse could be accused of the tort of assault. Battery is
the intentional touching of another’s body without the person’s consent. Slander is
verbal communication that is false and harms the reputation of another. Invasion of
privacy is committed when the nurse intrudes into the client’s personal affairs or
violates confidentiality.
Test-Taking Strategy: Note the subject, legal implications for nursing care.
Focusing on the words used by the nurse and noting that the nurse threatens the
client will direct you to the correct option.
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: Ethics; Health Care Law
Reference: Potter et al. (2017), p. 308.

911. Answer: 4

Rationale: When creating nursing assignments, the nurse needs to consider the
skills and educational level of the nursing staff. Frequent temperature checks and
ambulation can most appropriately be provided by the AP, considering the clients
identified in each option. The client on the mechanical ventilator requiring frequent
assessment and suctioning should most appropriately be cared for by the RN. The
LPN is skilled in urinary catheterization, so the client in option 4 would be assigned
to this staff member.
Test-Taking Strategy: Note the strategic word, best; focus on the subject, the
principles related to delegation and assignments; and consider the education and job
position as described by the Nurse Practice Act and employee guidelines. Note the
word assessment in option 3. This should alert you that this client should be assigned
to the RN. Options 1 and 2 can be eliminated because an AP can perform these tasks.
Level of Cognitive Ability: Creating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Planning
Content Area: Leadership/Management: Delegating/Supervising
Health Problem: N/A
Priority Concepts: Care Coordination; Safety
Reference: Lewis et al. (2017), pp. 11-12.

912. Answer: 1

Rationale: The jaw thrust without the head tilt maneuver is used when head or

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