The nursing student observes a staff nurse changing her behavior around a client. Signs that might be observed as professional boundary violations include: Standard Text: Select all that apply
1. The nurse calls the client by his or her first name
2. The nurse shares personal information with the client
3. The nurse touches the client without a therapeutic purpose
4. The nurse spends the same amount of time with this client as with other clients
5. The nurse reports receiving gifts from this client
1,2,3,5
Rationale: The nurse should call each client by their title and last name, for example Mr. Smith, rather than John.
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The nurse is providing initial screening to determine gross hearing acuity as part of a complete physical. Which of the following tests would the nurse include in the assessment?
a. Romberg b. Whisper voice c. Otoscopic examination d. Calorie test
Order: Heparin sodium 25,000 units in 250 mL DW IVPB, infuse at 1500 units /h. Calculate the flow rate in milliliters per hour
1. 15 mL/h 2. 17 mL/h 3. 25 mL/h 4. 12 mL/h
The boundaries of the neck's anterior cervical triangle are formed by the trachea, mandible, and
a. anterior cervical lymph nodes. c. sternocleidomastoid muscle. b. cervical vertebrae. d. trapezius muscle.
An older client who is hospitalized has been having difficulty sleeping since admission and is prescribed a low dose of zolpidem (Ambien). Why is the nurse most concerned about administering this medication?
1. It is not a natural option like melatonin. 2. It is associated with daytime hangover and sleepiness. 3. The client is documented as being on fall precautions. 4. The client takes diphenhydramine (Benadryl) for allergies.