A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?

Correct Answer: B

Rationale: The correct answer is B: Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. In a legal proceeding to determine if the nurse was negligent, the standard used is typically that of what a reasonable and prudent nurse would have done in the same situation. This standard is known as the "standard of care." It is important because it assesses the nurse's actions based on what is considered acceptable and appropriate within the nursing profession. Testimony from another staff nurse who can provide insight into how a reasonable and prudent nurse would have acted is crucial in establishing whether the nurse in question met this standard. Choice A is incorrect because testimony from an expert nurse about how the situation should have been handled differently may not necessarily reflect the standard of care for a reasonable and prudent nurse. Choice C is incorrect because the client's attorney stating that the injury could have been prevented does not establish the standard of care for a nurse in the situation. Choice D is incorrect because the client's provider

Correct Answer: B

Rationale: The correct answer is B. The nurse should assess the client who had an indwelling urinary catheter removed 5 hours ago and has not voided first. This is because urinary retention can lead to complications like urinary tract infection or bladder distention. It is important to monitor and address this promptly to prevent further issues. A: While a green gastric aspirate with a pH of 5.3 may indicate potential issues, it is not as urgent as urinary retention. C: A capillary refill time of 4 seconds in a client with COPD is concerning but does not require immediate attention compared to urinary retention. D: Fruity breath odor in a client with late-stage cirrhosis may indicate hepatic encephalopathy, which is serious, but urinary retention takes precedence due to the risk of immediate complications.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and acknowledges the staff nurse's feelings of frustration. By expressing understanding and empathy towards the staff nurse's situation, the charge nurse validates their emotions and shows support. This can help in de-escalating the situation and fostering a positive working relationship. Option A focuses more on the staff nurse's behavior rather than addressing the issue at hand. Option B offers a solution but does not address the emotional aspect of the situation. Option D places the blame on the staff nurse for not informing ahead of time, which can be counterproductive in resolving the immediate issue. Ultimately, option C is the most appropriate response in this scenario as it shows empathy and understanding towards the staff nurse's feelings.

Correct Answer: C

Rationale: Rationale for correct answer (C): 1. The nurse should promote client autonomy and informed decision-making. 2. Asking if the client has discussed other treatments shows respect for client preferences. 3. It encourages the client to consider all options before making a decision. 4. This response supports the client in making an informed choice based on available treatments. Summary of incorrect choices: A: Incorrect because it dismisses the client's question and rushes the consent process. B: Incorrect as it imposes the nurse's opinion on the client, which is not appropriate. D: Incorrect because it assumes the client does not want surgery without exploring other options.

Correct Answer: A

Rationale: The correct answer is A because activated charcoal works by adsorbing toxins in the stomach, preventing their absorption into the bloodstream. This helps decrease the body's absorption of the poison. Choice B is incorrect because charcoal does not form a compound with the poison. Choice C is incorrect because activated charcoal does not help to remove the poison from the body but rather prevents its absorption. Choice D is incorrect because it does not accurately describe the mechanism of action of activated charcoal in binding toxins. Overall, choice A is the most precise and scientifically accurate explanation of activated charcoal's function in cases of poisoning.