Accountability

Several nurses from the medical unit access the electronic medical record of a well-known public official who was admitted to the emergency department. How should the the nurse manager respond to the nurses regarding this situation?

"Accessing the official's medical record is a breach of confidentiality."

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

"I will not work tomorrow because I would be a danger to my clients."

A client of a homecare nurse gives the nurse an envelope with a small amount of money in it, stating, "It's a tip for the good care you give me." Which statement would be the most appropriate response from the nurse?

"I'm grateful that you're satisfied with the care you're recieving, but I can't accept any form of gift."

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage

A client has been diagnosed with Parkinson's disease and the primary health care provider has prescribed levodopa(100 mg)-carbidopa(10 mg) PO q8h. What is the nurse's best action?

Administer the medication as prescribed and monitor for therapeutic and adverse effects

A nurse is performing a physical examination of a pregnant woman. During examination, the nurse notices a bruise on the client's abdomen. Which action should the nurse take?

Ask the client to account for the bruise.

A new nurse is preparing to dispense medications to the assigned clients. The medications are provided by the pharmacy in individualized single-dose packaging. Which step is most important to ensure that each client receives the correct medication?

Compare the prescriber's original order with the label on the pharmacy package.

The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action?

Contact the health care provider for order clarification.

The nurse is caring for a technology-dependent school-aged child in his home. Which action best builds a trusting relationship?

Discussing care and treatment with the parent and child together

What is the main benefit of effective therapeutic communication for the nurse-client relationship?

Helps develop trust between nurse and the child.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

A client scheduled for the insertion of a percutaneous gastric feeding tube receives morphine 10 mg before the procedure. Upon review of the client's chart, the nurse notices that the client has not signed the consent form. Which is the nurse's priority action?

Inform the surgeon that the consent is not signed and that the client received morphine.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP?

Initiating intravenous therapy

The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the best action by the nurse?

Insert a new IV medication lock and remove the old one.

A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is most appropriate for the nurse-manager to take?

Meet with the new nurse and the primary nurse and help set up an additional week of orientation.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?

Notify the physician of the oversight.

If the dosage is inappropriate for a client, who is responsible?

Nurse

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

A nurse manager plans care for an 8-year-old child who requires around-the-clock care by unlicensed assistive personnel. How does the nurse best ensure safe care for the client?

Provide written instructions, education, and ongoing supervision.

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

A nurse working in the operating room is assigned to the suite where therapeutic abortions are to be performed throughout the day. The nurse feels that participation in these procedures conflicts with personal religious beliefs. What should the nurse do after notifying the operating room supervisor?

Remain in the operating room suite until another nurse arrives to take that assignment.

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions.

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

Respond verbally during the procedure

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

Which best exemplifies malpractice?

The nurse administers amoxicillin to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest.

A nurse is planning the discharge of a newborn to parents recently immigrated from Syria. Which action best indicates that the nurse provides culturally sensitive care?

The nurse researches the clients' cultural characteristics and beliefs.

A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client?

The student nurse, the nurse instructor, and the hospital

A client was admitted to a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?

Tort

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality?

determining that the client has authorized release of the information

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

remove gloves, remove gown, wash hands

What is the primary purpose of standards of nursing practice?

to ensure knowledgeable, safe, comprehensive nursing care

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

Which style of leadership is rarely used in a hospital setting because of the difficulty of task achievement by independent nurses?

Laissez-faire

A client has been diagnosed with an infection. The nurse can help to ensure the success of anti-infective treatment by:

confirming that the medication prescribed is the drug of choice for the specific microorganism.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation?

Notify the supervisor and call the police.

The client was admitted to the hospital with the diagnosis of iron overload. Over time, an excess of iron can damage the liver and cause heart problems. Which medication does the nurse anticipate the healthcare provider to order?

deferoxamine

A nurse preparing medication for a client is called away to an emergency. What should the nurse do?

Lock the medications in a cart and finish them upon return.

A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response?

State, "I cannot give medications for other nurses."

The nurse has confirmed the client's identity and provided a client with oral medications to take. What is the next appropriate nursing intervention?

Stay with the client while medications are taken.