Correct Answer: A

Rationale: The correct answer is A: Using silence. Silence in therapeutic communication allows the patient to collect their thoughts and express themselves without feeling rushed. It promotes reflection and deeper understanding. Offering sympathy (
B) may convey judgment or bias. Offering personal opinions (
C) can hinder open dialogue and may not be relevant to the patient's needs. Providing passive responses (
D) lacks engagement and may not address the patient's concerns effectively. In summary, using silence promotes active listening and allows for a more meaningful exchange in therapeutic communication.

Correct Answer: A

Rationale: The correct answer is A. By contacting the provider and completing an incident report, the nurse is demonstrating accountability, which is a key component of professionalism. Accountability involves taking responsibility for one's actions, acknowledging mistakes, and taking steps to rectify them. In this scenario, the nurse is taking proactive measures to address the error and prevent harm to the client.

Summary of other choices:
B: Accountability - This is the correct answer.
C: Confidence - Confidence is not the primary component being demonstrated in this scenario.
D: Fairness - Fairness is not directly related to the nurse's actions in administering the wrong medication.
E: Advocacy - While advocacy is important in nursing, it is not the primary focus in this situation where accountability is key.

Correct Answer: C

Rationale: Rationale for Correct Answer C: The nurse should secure the restraints using a quick-release tie to ensure the client's safety in case of an emergency. Quick-release ties allow for easy and rapid removal of restraints when necessary, preventing any delays in providing urgent care. This practice also aligns with patient rights and safety guidelines, promoting ethical and appropriate restraint use.

Summary of Incorrect

Choices:
A: Anticipating removing restraints every 4 hr is a general guideline for restraints, but securing them with a quick-release tie is more crucial.
B: Ensuring four fingers fit under restraints is important for proper fit but does not address the safety aspect provided by a quick-release tie.
D: Securing restraints to the lowest bar of the side rail may not facilitate quick release in emergencies and could potentially hinder easy removal.

Correct Answer: D

Rationale: The correct answer is D: Obtaining a blood pressure for a client who is to be discharged later in the day. The nurse can delegate this task to an assistive personnel (AP) as it is within their scope of practice and does not require critical thinking or decision-making skills. The AP can be trained to accurately measure blood pressure, ensuring the client's safety and well-being. Tasks A, B, and C involve more specialized knowledge and skills that only a nurse should perform.
Choice A requires specific training in tracheostomy care, choice B involves assessing a client post-surgery which may require critical thinking, and choice C involves teaching a preoperative client about using an incentive spirometer, which requires educational expertise.
Therefore, choices A, B, and C are not appropriate tasks for delegation to an AP.

Correct Answer: C

Rationale: The correct answer is C - The client's urine output has been 50 mL since surgery. This is important to report to the provider as it could indicate potential kidney dysfunction or inadequate fluid status postoperatively. Low urine output may be a sign of impaired renal function or inadequate fluid intake, which can lead to complications such as dehydration or acute kidney injury. It is crucial for the provider to be aware of this to intervene promptly.


Choice A is incorrect because serosanguineous drainage on the abdominal dressing is expected postoperatively.
Choice B is incorrect because the postoperative laboratory results of Hgb 15% and Hct 40% are within normal range.
Choice D is incorrect because a decrease in pain level post-morphine administration is an expected outcome.