Answer to Question 1
Answer: D
The nurse, recognizing that the client is no longer competent, should follow whatever hospital policy is in place for contacting the agent named in a durable power of attorney for health care. The physician is not the appropriate individual to make decisions for the client. Social services may be the department that would contact the agent of a durable power of attorney, but social services would not be that power. In the case of an incompetent client, the spouse would be the agent of the durable power of attorney only if the court appointed the spouse.
Answer to Question 2
Answer: A
According to the law, the primary healthcare provider must see the client and write a prescription for restraints within 1 hour of application. The nurse would apply the restraints to protect the airway and then immediately notify the primary healthcare provider. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.
The nurse applies a pulse oximeter sensor on the client’s finger.
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