Accountability

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take? Refuse to float to the ICU. Report to the ICU and accept a total client assignment; ask the nurses for assistance when necessary. Report to the ICU, tell the ICU nurses the pediatric nurse has never worked in the ICU, and let the nurses decide what tasks the pediatric nurse can perform. Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment.

Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment. Explanation: The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained to float in the ICU. The nursing supervisor can advise the pediatric nurse about tasks the pediatric nurse is qualified to perform in the ICU without jeopardizing the pediatric nurse's nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable way for managing resources. Having the ICU nurses determine what tasks the pediatric nurse can perform makes the ICU nurses responsible for the pediatric nurse's performance. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never accept responsibility for a total client care assignment if the nurse doesn't have the skills to plan and deliver care

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. Report the incidents to the facility's lawyer. Remind the residents and family members not to leave valuables unattended. Pass the information on to the doctor and the next shift staff.

Notify the supervisor and call the police. Explanation: The supervisor should be made aware of the situation and the police should be called to investigate the potential theft. The other answers do not advocate for the clients and their families. It is the responsibility of the nurse to take action because the nurse was the person to receive the information. This is known as due diligence.

A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What is the nurse's first responsibility in caring for this child? Place the child in a monitored room. Restrict the parent from the child's room. Report the incident to the proper authorities. Document all the areas of injuries.

Report the incident to the proper authorities.

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: Document the bruising and continue to assess the area over the next 72 hours. Report this finding to the nurse who is taking care of the client. Report this finding to the Adult Protective Services (APS). Report this finding to the physician.

Report this finding to the Adult Protective Services (APS). Explanation: Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS.

The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give hand-off reports at which time(s)? Select all that apply. when the nurse goes to lunch change of shift change of nurses when new medication prescriptions are written when the unit clerk goes to a staff meeting

change of shift change of nurses when the nurse goes to lunch Explanation: Effective communication is essential when managing client safety and preventing errors. "Hand-off reports" should be made at shift change, when there is a change of nurses or when the nurse leaves the unit, and when the client is discharged or transferred to another unit. There does not need to be a hand-off report when the unit clerk leaves the unit or when new medication prescriptions are written.

The student nurse is administering medications to the clients. The nurse educator asks the student, "Which of the medication orders have the potential to cause a medication error?" What is the best response by the student? Select all that apply. "every 4 hours" "QOD" "mL" "MgSO4" "cc"

"cc" "QOD" "MgSO4" Explanation: See Official Do Not Use list formulated by The Joint Commission. MgSO4: Can mean morphine sulfate or magnesium sulfate, and can be confused for one another. QOD: Period after the Q mistaken for "I" and the "O" mistaken for "I." cc: Mistaken for U (units) when poorly written. mL and every 4 hours are correctly written.

The healthcare provider orders a new medication for a 5-year-old client. The nurse educator asks the student, "What is a medication dose affected by?" What is the best response by the student? Select all that apply. "weight" "body build" "intake and output" "height" "disease state"

"disease state" "weight" Explanation: The drug dose is affected by weight and disease state, not by body build, height, or intake and output.

The nurse is precepting a graduate nurse and preparing to give infant immunizations. The preceptor asks the graduate, "Infant injections should only be given in which muscle?" What is the best response by the graduate nurse? "gluteus maximus" "rectus femoris" "deltoid" "vastus lateralis"

"vastus lateralis" Explanation: The vastus lateralis muscle is preferred until the deltoid muscle has developed adequate mass (approximately age 36 months). Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which is the junction of the upper and middle thirds of this muscle. The vastus lateralis is the preferred site for IM injection in infants under 12 months of age. The rectus femoris, and gluteus maximus sites are not developed as an infant.

A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip assessment of a client who has just returned from the postanesthesia care unit education about how to administer a heparin injection to a client diagnosed with deep vein thrombosis assistance with range of motion exercises for a client diagnosed with Alzheimer's disease administering a sitz-bath to a client who has had perineal surgery 2 days ago

1-vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip 2-assistance with range of motion exercises for a client diagnosed with Alzheimer's disease 3-administering a sitz-bath to a client who has had perineal surgery 2 days ago

An unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. What should the nurse do next? Readminister the residual to the client, and continue with the feeding. Delay feeding the client for 1 hour, and then recheck the residual. Dispose of the residual, and continue with the feeding. Withhold the tube feeding, and notify the health care provider (HCP).

Readminister the residual to the client, and continue with the feeding. Explanation: Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive, and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the HCP and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses.

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. Double check the medication in the package with a resource on the internet. Ask the client if the medications are the same as those taken at home. Have a second nurse verify the medications to be given.

Compare the prescriber's original order with the label on the pharmacy package. Explanation: The only way to determine the accuracy of the medication on hand is to verify it against the original order. The other options do not check the original order with the medication that is to be administered to the client.

An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination? Keep the client's friends (who are waiting in the lounge area) informed of her medical condition. Keep the suspected attacker away from the examination room. Leave the door open. Have a female health care worker present.

Have a female health care worker present. Explanation: A female health care provider should be present to observe an examination performed by a male health care provider. Leaving the door open and informing the client's friends about her condition violates her right to privacy and confidentiality. Although the suspected attacker should be kept away from the examination room, having a female health care worker present during the examination best protects the girl's rights.

A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply. Have two nurses check the blood type and identity. Initiate an IV with normal saline. Take baseline vital signs. Warm the blood to room temperature. Initiate an IV with dextrose.

Have two nurses check the blood type and identity. Initiate an IV with normal saline. Take baseline vital signs. Explanation: Prior to administering blood, the unit must be checked by two registered nurses. Baseline vital signs are obtained before the transfusion is started so any changes would be identified. Blood is always transfused with normal saline as other IV fluids are incompatible with blood. Warming to room temperature is not necessary.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? Inform the anesthesiologist. Note this new allergy prominently on the medical record. Administer the prescribed preanesthetic medication. Contact the scrub nurse in the operating room.

Inform the anesthesiologist. Explanation: The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The preanesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.

A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What is the nurse's first responsibility in caring for this child? Document all the areas of injuries. Place the child in a monitored room. Restrict the parent from the child's room. Report the incident to the proper authorities.

Report the incident to the proper authorities. Explanation: The nurse is required by law to report all incidents of abuse whether they be proven or suspected. In the hospital setting there is usually protocol as to the chain of command for reporting. In some facilities the nurse and/or healthcare provider should share the information about the injuries with the hospital social worker and the social worker contacts the police, Child Protective Services, or a children's aid society. In other facilities, the person seeing the abuse would report directly to the authorities. The healthcare provider and the nurse should document each of the injuries on the child, such as size and locations of bruises or open wounds, what stages of healing they are in, and if there is evidence of any broken bones or teeth. Once the case is investigated, the authorities will determine if monitoring is needed or if parents can visit with the child. Until abuse is proven, the parents are allowed to stay with the child.

A client arrives to the emergency department (ED), with reports of chest pain. Electrocardiograph (ECG) exhibits an elevated ST segment. What are the priority actions by the nurse? Select all that apply. eliminating stressors relieving pain preventing complications improving myocardial oxygenation reduce cardiac output

improving myocardial oxygenation relieving pain reduce cardiac output Explanation: Nursing care should focus on reducing cardiac output, improving myocardial oxygenation, and relieving pain. Stress cannot be eliminated, only reduced. Preventing complications is important, but secondary to reducing cardiac output, improving myocardial oxygenation, and relieving pain.

A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which would be the most appropriate response by the nurse to the surgeon? "I will get the consent signed right away and attach it to the chart." "I'll have the client sign, but you must explain the procedure before surgery." "I will explain the procedure and call you back if the client won't sign the consent." "It is your responsibility to obtain informed consent from the client."

"It is your responsibility to obtain informed consent from the client." Explanation: It is the surgeon's responsibility to obtain the informed consent after explaining the procedure to the client, including the risks, benefits, and alternatives. The other options are incorrect because they place the responsibility for obtaining informed consent on another person.

During an emergency, a physician has asked for I.V. calcium to treat a client with hypocalcemia. The nurse should: Hand the physician calcium chloride for I.V. use. Check with the physician for his complete order. Hand the physician the kind of calcium available on the unit. Hand the physician calcium gluconate for I.V. use.

Check with the physician for his complete order. Explanation: The nurse should first check with the physician for the complete order of calcium because calcium chloride has a concentration of 13.6 mEq (3.4 mmol/l) of calcium per gram and calcium gluconate has 4.65 mEq (1.2 mmol/l) of calcium per gram. The nurse can always offer the doctor the type of calcium available after the conversion in calcium has been made; otherwise, the error could be fatal.

A client with ascites is experiencing severe respiratory distress and refuses endotracheal intubation. What should be the nurse's first action? Have the client sign a do-not-resuscitate (DNR) form. Determine whether the family has been consulted. Inform the physician of the client's decision. Determine whether the client is competent to make the decision.

Determine whether the client is competent to make the decision. Explanation: Informed decision-making requires that the decision be voluntary, that the client have the capacity and competence to understand their decision, and that the client have adequate information on which to base the decision. In this instance, the nurse must determine whether the client is competent to refuse endotracheal intubation because severe respiratory distress leads to hypoxemia, which may impair the client's ability to make the decision. The nurse should inform the physician of the client's decision after determining the client's competency. A DNR form requires a physician's order, and the physician is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights guarantees the client autonomy to make decisions about their care plan, including the right to refuse recommended treatment. As an advocate, the nurse should support the client's decision, which may be in opposition to family members' opinions.

The nurse is documenting medication administration at the bedside and realizes docusate sodium was administered to the wrong postpartum client. Which action should the nurse take first? Disclose the error to the client. Complete an incident report. Retrieve the client's allergy data. Complete a head-to-toe assessment.

Disclose the error to the client. Explanation: Nurses should uphold the standards for safe, competent, and ethical care and ensure personal and professional accountability as per the American Nurses Association (Canadian Nurses' Association) Code of Ethics. The nurse has an ethical obligation to be truthful with the client. The error should be disclosed and explained openly. The nurse can ask the client about allergies at that time as well. Though an incident report will need to be completed, this will take place later. An assessment should be performed, but there will be no effects from swallowing oral docusate sodium in the first few minutes! Even if the error seems benign, the same ethical and policy guidelines apply.

A nurse observes a second nurse documenting a peripheral blood glucose level that the second nurse did not actually collect from a client with diabetes. What is the priority action by the nurse observing this situation? Do the blood glucose level on the client for the other nurse. Strike through the entry that the nurse documented. Discuss the observation with the other nurse. Document the nurse's behavior on the client's chart.

Discuss the observation with the other nurse. Explanation: The first action the nurse should take is to discuss what was witnessed with the other nurse and express concern that this behavior is unethical, unprofessional, and illegal. The nurse manager should be notified in order to follow up with the nurse. Documenting assessments that were not actually done on a legal document is illegal and constitutes professional misconduct. The other options do not reflect safe and competent care, nor do they protect the client.

A nurse who works on a psychiatric unit arrives to work disheveled, unkempt in appearance, and smelling of alcohol. What is the best approach for the nurse's colleague on the night shift to manage this situation? Immediately report the concern to the appropriate leader or manager in charge. Support the coworker because the nurse in question is a professional and responsible. Encourage the nurse to report in as sick and hope the unit can get a replacement. Monitor the behavior during the shift and follow up if anything is forgotten with client care or shift responsibilities.

Immediately report the concern to the appropriate leader or manager in charge. Explanation: It is important that the nurse report unsafe practice of nursing colleagues to the appropriate authority. Waiting to observe for future problems is not adequate to address immediate professional or safety concerns. A nurse must support the profession and care of clients, and it would be professionally irresponsible to support a nurse colleague who is unfit for practice. Asking the nurse to call in sick merely masks the problem.

A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation? Inform the nurse that selling supplements to clients is a conflict of interest. Report the nurse to the nurse manager and the nursing regulatory body. Interview the nurse's other clients to see if the nurse attempted to sell supplements to them. Tell the client that the client should not purchase anything from the nurse.

Inform the nurse that selling supplements to clients is a conflict of interest. Explanation: The first nurse is offering advice outside the scope of practice for an RN and could be accused of diagnosing and prescribing. The nurse is also working outside the therapeutic relationship. The client may feel pressured to purchase the supplements to get nursing care or further assistance from the nurse, which puts the nurse in a position of power over the client. It is not appropriate to tell the client to not purchase supplements from the nurse. It is also not appropriate to interview the nurse's other clients. Finally, as a professional, the second nurse should address the behavior with the colleague first and provide a teaching opportunity. If the first nurse does not agree to stop, or is found engaging in the behavior again, then reporting to the manager and regulatory body is appropriate

A client has been diagnosed with bacterial pneumonia. After 1 day of IV antibiotic therapy, the client's white blood cell count is still 14,000/mm3 (14 × 109/L). What should the nurse do next? Initiate reverse isolation precautions. Administer the next scheduled antibiotic dose early. Recheck the client's white blood cell count in 24 hours. Notify the health care provider.

Notify the health care provider. Correct response: Notify the health care provider. Explanation: If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The health care provider should be notified as they may want to consider changing antibiotics. While rechecking the client's white blood cell count may be appropriate, it is the health care provider's responsibility to make this decision. Reverse isolation is used for clients with a very low white blood cell count. The antibiotic dosing schedule should be strictly maintained.

A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse? Refuse to administer the placebo to the client. Give the placebo as ordered by the physician. Give the placebo but do not tell the client it is a stronger medication. Consult with the pharmacist to discuss the dosage of the placebo.

Refuse to administer the placebo to the client. Explanation: The nurse should refuse to give the placebo and should also refuse to misinform the client. The nurse has a responsibility to explain the client's medications to the client. The client can then make an informed decision about accepting or refusing the medication. The other options are incorrect because the nurse would be misinforming the client about the medication that is being administered. The client would not be able to provide informed consent

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Send the colleague an anonymous card. Post accolades to the nurse at the nurses' station. It is a breach of confidentiality to share this information with the colleague. Share the feedback with the nursing colleague directly.

Share the feedback with the nursing colleague directly. Explanation: It is not a breach of confidentiality for the nurse to share the feedback with the colleague, and by doing so the nurse will recognize the value of the colleague's professional efforts and accomplishments. It is not appropriate to place an announcement at the nurses' station or to send an anonymous card. It is crucial that nurses uphold the standards for professional practice and consider the American Nurses Association (Canadian Nurses' Association) Code of Ethics, in particular surrounding the principles of preserving dignity and maintaining privacy and confidentiality.

A client is having a blood transfusion reaction. What must the nurse do in order of priority from first to last? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1-Notify the health care provider (HCP) and blood bank. 2-Stop the transfusion. 3-Keep the intravenous (IV) line open with normal saline infusion. 4-Complete the appropriate transfusion reaction form(s).

Stop the transfusion. Keep the intravenous (IV) line open with normal saline infusion. Notify the health care provider (HCP) and blood bank. Complete the appropriate transfusion reaction form(s). Explanation: When the client is having a blood transfusion reaction, the nurse should first stop the transfusion and then keep the IV open with a normal saline infusion. Next, the nurse should notify the HCP and blood bank and then complete the required form(s) regarding the transfusion reaction.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager? Because the nurse-manager is off duty and not accountable for incidents that occur in their absence, the nurse-manager need not be notified. The nurse-manager only needs to be informed of the incident when the nurse-manager reports to work on the next scheduled day. The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. Although the nurse-manager is off duty and not responsible for what happened, the nursing supervisor would call the nurse-manager only if time permits.

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. Explanation: The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. None of the other choices accurately reflect the nurse--manager's accountability in this situation.

A client has been prescribed neomycin and polymyxin B sulfates and hydrocortisone otic suspension, two drops in the right ear. What action is most important for the nurse take when instilling the medication? Verify the proper client and route. Warm the solution to prevent dizziness. Position the client in the semi-Fowler's position. Hold an emesis basin under the client's ear.

Verify the proper client and route. Explanation: When giving medications, a nurse should follow the "rights" of medication administration, which include verification of right client and right route. The drops may be warmed to prevent pain or dizziness, but this action isn't essential. An emesis basin would be used for irrigation of the ear. The client should be placed in the lateral position for five minutes, not semi-Fowler's position, to prevent the drops from draining.

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alfa as alternatives to a blood transfusion. Which response by the nurse causes the supervising nurse to plan a review of professional and ethical standards? "Do you have all the information you need for informed consent?" "Do you have any questions that I can clarify for you?" "Tell me how the nurse educator explained the procedure." "You should take the unit of blood. It will help you feel better."

"You should take the unit of blood. It will help you feel better." Explanation: Stating that the client should accept a blood transfusion is a violation of professional and ethical standards since the nurse is exercising undue influence on the client's choice. Therefore, if the nurse gives this response, a review of standards is needed. To give informed consent, the client must have all the information and understand it, and all of the client's questions should be answered. The other statements would indicate that the nurse understands this principle.

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alfa as alternatives to a blood transfusion. Which response by the nurse causes the supervising nurse to plan a review of professional and ethical standards? "Do you have all the information you need for informed consent?" "Do you have any questions that I can clarify for you?" "You should take the unit of blood. It will help you feel better." "Tell me how the nurse educator explained the procedure."

"You should take the unit of blood. It will help you feel better." Explanation: Stating that the client should accept a blood transfusion is a violation of professional and ethical standards since the nurse is exercising undue influence on the client's choice. Therefore, if the nurse gives this response, a review of standards is needed. To give informed consent, the client must have all the information and understand it, and all of the client's questions should be answered. The other statements would indicate that the nurse understands this principle.

During assessment, a client verbally rates pain as 9 out of 10 on a 0-10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next? Notify the supervisor that the client did not receive the prescribed pain medication. Notify the pharmacist that the client did not receive the prescribed pain medication. Notify the health care provider that the client is confused and pain is poorly controlled. Approach the nurse who signed for the opioid to seek clarification about the missing drug.

Approach the nurse who signed for the opioid to seek clarification about the missing drug. Explanation: The nurse should not assume the client is confused but should instead investigate why the pain is poorly controlled. Given the scenario, the nurse needs to rule out the possibility that the other nurse has signed for a medication that was not administered. This requires asking the other nurse directly about the situation. Neither the supervisor nor pharmacist should be involved until after the situation is investigated with the nurse in question.

A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask? Are you comfortable performing the tasks assigned? What is your highest educational level? How long have you worked on this floor? Which task would you prefer to perform?

Are you comfortable performing the tasks assigned? Explanation: Because the float nurse is not familiar with staff, it is important to ask the other staff if they are comfortable and had instruction in the task assigned. Principles of delegation state that the right task in the right situation by the right personnel is essential to client care. Asking the highest educational level, how long they worked on the floor, and personal preference is not as important as if they are comfortable with performing the task.

A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask? What is your highest educational level? How long have you worked on this floor? Which task would you prefer to perform? Are you comfortable performing the tasks assigned?

Are you comfortable performing the tasks assigned? Explanation: Because the float nurse is not familiar with staff, it is important to ask the other staff if they are comfortable and had instruction in the task assigned. Principles of delegation state that the right task in the right situation by the right personnel is essential to client care. Asking the highest educational level, how long they worked on the floor, and personal preference is not as important as if they are comfortable with performing the task.

The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. How should the nurse best intervene? Assess the client's injury, offer the client a bandage wrap, and document the incident. Assess the client's injury, offer the client an ice pack, and document the incident. Report the client's injury to the healthcare provider, offer to assist with ambulation, and document the incident. Assess the client's injury, notify the healthcare provider, and document the incident.

Assess the client's injury, notify the healthcare provider, and document the incident. Explanation: The nurse should assess the injury, notify the healthcare provider, and thoroughly document the incident in accordance with facility protocol. Even though a patient with somatic symptom disorder is likely to have many physical complaints, the nurse should thoroughly investigate each complaint to avoid overlooking a serious problem. The nurse should always notify the healthcare provider of the findings in accordance with facility protocol.

The nurse is unable to find the health record (chart) for a client who has arrived for a clinic visit. Which is the best action by the nurse? Document the information about the visit on paper, and transcribe these notes into the client's medical record once it is located. Call one of the client's other healthcare providers to request that a copy of the medical records for the client be sent to the clinic. Advise the client that the appointment will have to be rescheduled due to the fact that the medical record cannot be located. Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later.

Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. Explanation: Documentation is an essential and legal component of providing care to clients. Information must be documented as it is collected. The nurse should not send the client away without the client getting the care that was to be provided. Therefore, the nurse creates a new record that contains all the client's appropriate identifiers so this can be added to the client's primary medical record when it is located. The nurse should be truthful about the missing records and should avoid transcribing notes whenever possible to avoid data errors. Another healthcare provider's records are not a substitute for the health record specific to this clinic. Requesting records from another provider would only be appropriate if relevant to the client's current reason for the visit and if the client consented to the transfer of this information.

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate for preeclampsia, the magnesium sulfate rate is found to be infusing well below the prescribed rate. After the nurse adjusts the infusion rate and notifies the health care provider (HCP), what is the most important action by the day nurse? Ask the charge nurse if an incident report is necessary. Complete an incident report. Discuss the matter with the night nurse the next time they work. Evaluate the client's vital signs for 4 hours before making a decision.

Complete an incident report. Explanation: Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? Notify the local nursing regulating body about the unsafe working conditions at the facility. Create the client assignment by considering available staff's skill level and client needs. Call charge nurses on other units to request a registered nurse come assist on the unit. Refuse to create the client assignment and tell management that a nurse must be found.

Create the client assignment by considering available staff's skill level and client needs. Explanation: When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members. The charge nurse's primary duty is to the safety of the clients. If there were serious impediments to safely adjusting the workload, it may be reasonable to voice this concern to the management, but the priority is to attempt to create the safe client assignment within the current staffing realities. The nurse should not attempt to arrange for staffing independently by calling other charge nurses as this is outside the role and responsibilities and may create safety concerns on other units. If the working conditions are considered unsafe, this could be a matter to be brought forward to a regulating body. However, in the moment, the charge nurse's priority is to attempt to distribute the clients' care in a safe manner.

A client tells the visiting community health nurse that another client's name and phone number were seen on the call display after the previous day's nurse used the client's home phone. What should the nurse do in response to this conversation? -Discuss the matter with the other nurse, reminding the other nurse not to use the client's phone because it has a call display feature. -Instruct the client not to look at the call display after the nurse leaves because it contains confidential information. -Tell the client that the other client is on the nurse's list of clients, but do not disclose any further information. -Ask the client to visit the other client because the other client is lonely and would enjoy the company.

Discuss the matter with the other nurse, reminding the other nurse not to use the client's phone because it has a call display feature. Explanation: Leaving personal information in view of other people is a breach of confidentiality. The nurse should inform the other nurse of the incident. The other options are incorrect because they do not protect the client's privacy and do not address the behavior of the other nurse.

While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that person doing who lost their baby from prematurity? We were in labor together." Which response by the nurse would be most appropriate? Tell the client, "I'm not sure how the other person is doing today." Ignore the client's question and continue with morning care. Explain to the client that "nurses are not allowed to discuss other clients on the unit." Tell the client, "I need to ask their permission before discussing their well-being."

Explain to the client that "nurses are not allowed to discuss other clients on the unit." Explanation: Legal regulations and ethical decision-making require that the nurse maintain confidentiality at all times. The nurse's best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client's question is inappropriate because doing so would interfere with the development of a trusting nurse-client relationship. Confidentiality must be maintained at all times. Telling the client that the nurse is not sure may imply that the nurse will find out and then tell the client about the other woman. Asking the other client for permission to discuss their situation is inappropriate because confidentiality must be maintained at all times.

The nurse is caring for a client who continues to be confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to understand. To maintain client safety, the nurse should do what first? Contact the health care provider, and request a prescription for soft wrist restraints. Ask the family to stay with the client. Increase the frequency of client observation. Administer a sedative.

Increase the frequency of client observation. Explanation: The first intervention for a confused client is to increase the frequency of observation, by moving the client closer to the nurses' station if possible and delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family can stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may potentiate the problem.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? Contact the scrub nurse in the operating room. Withhold the prescribed preanesthetic medication. Note this new allergy prominently on the medical record. Inform the anesthesiologist.

Inform the anesthesiologist. Explanation: The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The nurse should first notify the anesthesiologist of the allergy; it is not the nurse's responsibility to withhold the preoperative medications unless the anesthesiologist rewrites the preoperative orders. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure and does not determine if the client's allergy will cause the surgery to be canceled.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions? Have the LPN take the vital signs again, phone the operating room, and cancel the surgery. Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. Take the vital signs, and in the future do not delegate this preoperative responsibility. Sign off the chart but flag that vital signs are abnormal; allow the client to go to the operating room.

Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. Explanation: The purpose of a registered nurse's signing off the chart is to ensure that the safety of the client has been assessed. Abnormal vital signs identify that priority systems indicate that a stressor or infection is present.

An older adult client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. The client's adult child lives with them to help the client manage daily activities. The client attends a daycare program for seniors during the week while the caregiver works. A nurse at the daycare center hears the client say, "If my neighbor puts up a fence, I'll blow them away with my shotgun. They've never respected my property line, and I've had it!" Which action should the nurse take? Observe the client more closely, but do not report the threat since the client will likely not be able to follow through with it because of his dementia. Report the comment to the neighbor, the intended victim, but refrain from telling the caregiver since they will worry about Report the comment to the neighbor, the caregiver, and the police since there is the potential for a criminal act

Report the comment to the neighbor, the caregiver, and the police since there is the potential for a criminal act. Explanation: The neighbor could be harmed as well as the caregiver if they should try to stop the client from using the gun, so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so (and to document it) can result in civil penalties levied against the nurse. The client's early dementia would likely not prevent them from carrying through with the threat.

A child is brought to the clinic by a grandparent who states that someone may have sexually abused the child. The grandparent noticed blood and a discharge on the child's underpants. After the child is assessed and treated for injuries, what is the priority intervention by the nurse? Report the suspicion to the appropriate authorities. Ask the grandparent who else was caring the child during the past 24 hours, Notify the child's health care provider so the authorities can be contacted. Ask the child if anyone touched the private area.

Report the suspicion to the appropriate authorities. Explanation: The nurse's responsibility is to report the incident to the appropriate authorities so that the situation can be investigated. The nurse needs to report the suspicion of abuse to the authorities, not to the health care provider. The safety of the child is of the utmost importance, and asking people who cared for the child will be done with the authorities. The nurse should not question the child about inappropriate touching without the authorities present.

A child is brought to the clinic by a grandparent who states that someone may have sexually abused the child. The grandparent noticed blood and a discharge on the child's underpants. After the child is assessed and treated for injuries, what is the priority intervention by the nurse? Report the suspicion to the appropriate authorities. Notify the child's health care provider so the authorities can be contacted. Ask the child if anyone touched the private area. Ask the grandparent who else was caring the child during the past 24 hours,

Report the suspicion to the appropriate authorities. Explanation: The nurse's responsibility is to report the incident to the appropriate authorities so that the situation can be investigated. The nurse needs to report the suspicion of abuse to the authorities, not to the health care provider. The safety of the child is of the utmost importance, and asking people who cared for the child will be done with the authorities. The nurse should not question the child about inappropriate touching without the authorities present.

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. What should the nurse do? Ask the nurse if the nurse has been drinking. Report this to the nursing supervisor immediately. Assess the nurse's behavior for signs of intoxication. Report this to the head nurse in the morning.

Report this to the nursing supervisor immediately. Explanation: This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed until the head nurse is available on the day shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.

A nurse is caring for a client with a central venous catheter who needs a dressing change. The nurse is uncertain about performing the procedure. What action will be most appropriate for the nurse to do first? Explain concerns about uncertainty to the client during the procedure. Perform the dressing change as best as possible. Have the nurse on the next shift complete the procedure. Review the facility's procedure for the steps to complete.

Review the facility's procedure for the steps to complete. Explanation: The nurse should apply independent problem-solving and clinical reasoning as a first action. This would include reviewing the policy and procedure. It is likely still necessary for the nurse to collaborate with a colleague or manager, but independent problem-solving should be applied as an initial action. Performing the procedure when uncertainty could lead to client injury and sharing the uncertainty with the client is inappropriate

A client with chronic obstructive pulmonary disease has a new prescription for theophylline. Which information obtained from the client would prompt the nurse to consult with the healthcare provider? The client is not experiencing any shortness of breath at present. The client is coughing up thick mucus. The client's heart rate increases from 72 to 81 beats per minute while walking in the hall. The client takes cimetidine 150 mg daily.

The client takes cimetidine 150 mg daily. Explanation: Cimetidine interferes with the metabolism of theophylline and may cause theophylline toxicity. Theophylline should be taken as prescribed even if the client is not experiencing any symptoms of shortness of breath. An elevated heart rate is an expected side effect of theophylline and moderate exercise in a client with COPD. Thick mucus production is also an expected symptom of COPD.

A nurse manager identifies fall prevention as a unit priority. Which actions can the nurses implement to meet these goals? Select all that apply. Make hourly rounds to client rooms. Close doors to client rooms at night. Use bed alarms to remind clients to call for help getting up. Maintain a clear path to client bathrooms. Apply soft waist restraint to confused clients.

Use bed alarms to remind clients to call for help getting up. Maintain a clear path to client bathrooms. Make hourly rounds to client rooms. Explanation: Client falls occur most often when there is need for assistance, but the client has not called for help. Frequent rounding, clear path to all bathrooms, and bed alarms for forgetful clients all have been shown to reduce client falls. Restraints should not be used without an order, or when a less-restrictive approach can be used. Closed doors at night will not reduce the risk for falls, but may increase them if the room is too dark or the nurses do not see the client in an unsafe situation

A nurse manager identifies fall prevention as a unit priority. Which actions can the nurses implement to meet these goals? Select all that apply. Make hourly rounds to client rooms. Close doors to client rooms at night. Apply soft waist restraint to confused clients. Use bed alarms to remind clients to call for help getting up. Maintain a clear path to client bathrooms.

Use bed alarms to remind clients to call for help getting up. Maintain a clear path to client bathrooms. Make hourly rounds to client rooms. Explanation: Client falls occur most often when there is need for assistance, but the client has not called for help. Frequent rounding, clear path to all bathrooms, and bed alarms for forgetful clients all have been shown to reduce client falls. Restraints should not be used without an order, or when a less-restrictive approach can be used. Closed doors at night will not reduce the risk for falls, but may increase them if the room is too dark or the nurses do not see the client in an unsafe situation.

The nurse is helping to prepare a client for nonemergency surgery. What should the nurse do? Verify that the client understands the informed consent form. Explain the surgical procedure in detail. Inform the client about the risks of the surgery to be performed. Obtain informed consent from the client.

Verify that the client understands the informed consent form. Explanation: The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications and that consent for the surgery is truly voluntary

The health care provider (HCP) is calling in a prescription for ampicillin for a neonate. What should the nurse do? Select all that apply. Repeat the prescription to the HCP over the telephone. Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse. Write down the prescription. Ask the HCP to come to the hospital and write the prescription on the medical record. Ask the HCP to confirm that the prescription is correct.

Write down the prescription. Repeat the prescription to the HCP over the telephone. Ask the HCP to confirm that the prescription is correct. Explanation: The nurse should write down the prescription, read the prescription back to the HCP, and receive confirmation from the provider that the prescription is correct as understood by the nurse. It is not necessary for the HCP to come to the hospital to write the prescription on the medical record or to have the nursing supervisor cosign the telephone prescription.

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? flurazepam deferoxamine ramipril montelukast

deferoxamine Explanation: Deferoxamine is used for the treatment of iron overload by ridding the body of the extra iron. Montelukast is a bronchodilator used for chronic asthma. Ramipril is a antihypertensive used to treat hypertension. Flurazepam is a sedative/hypnotic that is used for insomnia.

A nurse who is working with a nursing assistant is making care assignments for the shift. Which task would be appropriate for the nurse to delegate to the nursing assistant? Select all that apply. documenting oral intake on the I&O flow sheet checking vital signs assisting with a bed bath for a client who had surgery yesterday evaluating a client's response to administered pain medication assessing a client's bowel sounds

documenting oral intake on the I&O flow sheet checking vital signs assisting with a bed bath for a client who had surgery yesterday Explanation: When delegating client assignments and tasks, the nurse must make sure that the tasks assigned meet the training and educational level of the person to whom the task was assigned. It would be appropriate for the nurse to assign tasks such as checking vital signs, documenting oral intake, and assisting with hygiene measures. Evaluating a client's response to pain medication and assessing a client's bowel sounds are higher level, skilled tasks that the registered nurse must perform.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care? counseling the person committing the abuse documenting the situation and providing support for the victim counseling the victim protecting the client's safety by completing an incident or occurrence report

documenting the situation and providing support for the victim Explanation: The nurse must carefully and adequately document the assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. The nurse should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? submitting the incident report to the appropriate hospital administrator making a copy of the incident report for the client notifying the health care provider of the incident and the client's condition documenting the incident factually in the client's record

making a copy of the incident report for the client Explanation: A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.

Which client is most appropriate for the registered nurse to assign to the licensed practical nurse (LPN)? multiparous woman with Enterobacter cystitis and sickle cell crisis multiparous woman who just received ergonovine maleate (Methergine) multiparous woman with polymicrobial necrotizing fasciitis. multiparous woman with Klebsiella pneumoniae cystitis

multiparous woman with Klebsiella pneumoniae cystitis Explanation: The klebsiella pneumoniae organism is a common cause of cystitis. The care of this client is appropriate for the registered nurse (RN) to delegate to the LPN. Ergonovine is ordered for postpartum hemorrhage. Because the client recently received the medication, she might be unstable, which would require the RN's assessment skills. Enterobacter commonly causes cystitis; however, the client's condition is complicated by sickle cell crisis, which requires the care of an RN. Necrotizing fasciitis is characterized by erythema, discharge, severe pain, severe tissue necrosis, and partial liquefaction of fascia; the severity of the disease requires that an RN administer care.

A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should have the client sign the form and ask the physician explain the procedure again. explain the form and have the client's healthcare power of attorney sign it. explain the procedure and the benefits and risks associated with it, then have the client sign the form. notify the physician that the client doesn't understand the procedure.

notify the physician that the client doesn't understand the procedure. Explanation: Informed consent requires that four essential elements be satisfied: competence, adequate disclosure, sufficient comprehension, and client voluntariness. The client must be mentally competent to give consent. The client must receive adequate information on which to base an informed decision. This information includes the nature of the procedure, expected benefits and positive outcomes of the procedure, potential risks or negative outcomes of the procedure, potential risks if the client chooses not to have the procedure, and available alternative therapies and their risk and benefits. The client must sufficiently comprehend this information and must be free to decide without coercion. The physician or the person who will perform the procedure is responsible for securing informed consent. A nurse witnesses the client's signing of the consent form and validates the client's identity, mental status, and voluntary signature