Critical care and emergency prep u
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb all the way up to the hips. What should the nurse do next? Select all that apply
•Notify the health care provider (HCP) of the change. •Place respiratory resuscitation equipment in the client's room. •Check for advancing levels of paresthesia. Rationale: • A client who has been admitted for numbness and tingling in the lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The HCP must be notified of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing. The family does not need to be called in to visit until the client is stabilized and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the numbness or change the course of the disease.
A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which action?
Consulting with the physician about a care plan
The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process?
Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility
The nurse is assigned to care for 4 mothers and their term newborns. Which mother and newborn couplet requires the nurse's attention first?
Mother: fundus firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute
A client is being prepared for a bronchoscopy. The nurse can delegate which task to the unlicensed assistive personnel (UAP)?
placing the client on NPO status
A primigravid client at about 36 weeks' gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which person must the nurse notify?
primary care provider who will attend the birth of the infant
The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux disease. The first step should be to search for:
published national standards
A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to:
reassign the client to another nurse who is experienced in blood administration
A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
suggest referral to a sex counselor or other appropriate professional
In which situation can a client's confidentiality be breached legally?
when a client near discharge is threatening to harm an ex-partner
A client has been admitted to the medical surgical unit following an emergency cholecystectomy. There is a Jackson Pratt drain with a portable suction unit attached. After 4 hours, the drainage unit is full. What should the nurse do?
• Empty the drainage unit.
The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
• Obtain vital signs. • Apply antiembolic stockings. Keep the client oriented
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding?
evidence of spontaneous rupture of the membranes
The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should:
explain how to overcome a freezing gait by telling the client to march in place.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
graphic sheet
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
impaired gas exchange
Which nursing diagnosis takes highest priority for a client with a compound fracture?
Risk for infection related to effects of trauma
Which statement indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan?
The client agrees to call the health care provider (HCP) if dyspnea on exertion increases.
A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply
• The physician was correct to stop resuscitation efforts. • By calling a code blue, the nurse disregarded the client's advance directives and DNR order.
Four people who have been injured in a car accident are admitted to the emergency department. Using the Emergency Severity Index (ESI), in which order should the victims be seen by a health care provider (HCP)?
• an adult with severe bleeding from a laceration in the leg • an adult with a history of asthma and respirations of 30 breaths per minute • a child with lacerations on the arms and legs • an older adult with normal vital signs, but is confused
The charge nurse in the newborn nursery has an unlicensed assistive personnel (UAP) with her for the shift. Under their care are 8 babies rooming in with their mothers, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply
• vital signs on all stable infants • document feedings of infants • record voids/stools
The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which statement best describes the nurse's response?
A violation of confidentiality because she informed the officer that the client wasn't there
A nursery nurse just received the shift report. Which neonate should the nurse assess first?
Four-hour-old term neonate with jaundice
Thirty people are injured in a train derailment. Which client should be transported to the hospital first?
a 25-year-old with a sucking chest wound
Which of the following theories of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?
care-based ethics
A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?
"By discharge, the client correctly identifies three potassium-rich food sources."
A hospital uses the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry?
"Client reporting abdominal pain rated at 8/10."
Which statement reflects appropriate documentation in the medical record of a hospitalized client?
"Client's skin is moist and cool."
The nurse is teaching two unlicensed assistive personnel (UAP) who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which statement is made?
"I need to check the client precisely at 15-minute intervals."
A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholycystectomy later in the day, the client asks the nurse why the procedure is needed. Which of the following is the appropriate response by the nurse?
"I will ask the surgeon to come speak to you about the procedure."
The nurse is instructing an unlicensed assistive personnel (UAP) on the prevention of postoperative pulmonary complications. Which statement indicates that the UAP has understood the nurse's instructions?
"I will have the client take 5 to 10 deep breaths every hour."
A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client's room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma?
"If you're thinking about organ donation, my sister is waiting for a kidney transplant. She'd be an excellent recipient. I can give you her phone number."
The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who has a newly applied long-leg plaster cast. What should the nurse tell the UAP about proper care of the cast while it is drying?
"Turn the client every 2 hours to promote even drying of the cast."
The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent:
"Your son can make an e-health history to facilitate his care if he gets sick away from home."
The nurse is caring for a client with end-stage cancer whose health status is declining. A prescription is written by the attending health care provider (HCP) to withhold all fluid, but the health care team cannot locate a family member or guardian. The nurse requests an ethics consultation. Which information is true of an ethics consultation? Select all that apply.
-Persons requesting an ethics consultation may do so without intimidation or fear of reprisal. •Ethics consultations may prevent poor outcomes in cases involving ethical problems. - The recommendations of ethics consultants are advisory only.
Which task should a nurse choose to delegate to a nursing assistant? Select all that apply.
-vital signs -documenting oral intake -blood glucose check
The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from social work or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship?
Communication barriers between the mother and staff
The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first?
Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity.
Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner?
Conduct a class for clients who require the same discharge teaching
A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response?
Confer with the HCP about whether a less expensive drug could be prescribed.
A primary unit nurse tells the nurse-manager that a newly hired registered nurse needs an additional week of orientation in order 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
A nurse is caring for a client who is well known in society. A person inquires about the medical details of the client, saying that he is a family member. The nurse reveals the requested information. Later, the nurse comes to know that the inquirer was not a family member. Which of the following ethical rules of professional-client relationships has the nurse violated?
Confidentiality
The nurse is caring for an adult client who had a gastric resection on November 4. At 1700 the following day, the client requests pain medication. The client's health care provider has prescribed meperidine, 75 to 100 mg every 3 to 4 hours. The nurse reviews the client's progress notes (view the chart). What should the nurse do next?
Administer the pain medication as requested
A nurse is working within the managed care delivery model. Which of the following is true regarding managed care?
All systems reflect the values of efficiency and effectiveness
A nurse having difficulty setting up humidified oxygen at 40% per Venturi mask doesn't know how many liters of flow she should use. Which intervention should the nurse perform to ensure that the oxygen is properly administered?
Consult with a respiratory therapist.
A nurse is prioritizing care for four new admissions to the inpatient psychiatric unit. Which client should the nurse assess first?
A client with new-onset confusion and disorientation
A pediatric nurse preceptor working on an oncology floor observes a new graduate crying in the nurses' lounge. What is the nurse's best action?
Ask the graduate what's going on.
A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation?
Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members.
A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort?
Assault rationale: Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care
The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do?
Assess the client to determine why she wants to sit up
A client reports having pain in the casted left arm that is unrelieved by pain medication. The nurse assesses the arm and notes that the fingers are swollen and difficult to separate. What should the nurse do first?
Call the health care provider (HCP) to report swelling and pain.
What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home?
Checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment
Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills?
Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care.
A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?
Decreased cardiac output
A client receiving chemotherapy for cervical cancer indicates that she has an advance directive. She tells the nurse that she worries her children will not honor her wishes if her condition should worsen. In order to facilitate the honoring of the client's wishes, what should the nurse encourage the client to do?
Discuss her end-of-life wishes with her family
The nurse is caring for a client with a subdural hematoma. Which of the following is the priority outcome?
Ensure airway patency and optimal oxygen levels and protect from injury.
After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which of the following actions by the nurse is most appropriate?
Enter the information tomorrow stating it is a late entry
Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client?
Follow the chain of command to obtain adequate pain relief for the client.
A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care?
Good Samaritan laws are designed to protect the caregiver in emergency situations
The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child's allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents
Identifying ways to reduce the child's exposure to the allergens
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first?
Initiate fetal and contraction monitoring.
In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which of the following professional values?
Integrity
A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next?
Notify the physician that the client has no vital signs
A client is scheduled for surgery at 8 a.m.(0800). While completing the preoperative checklist, the nurse sees that the surgical consent form isn't signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation?
Notifying the surgeon that the client hasn't signed the consent form
A nurse is caring for a 14-month-old infant being treated for an upper respiratory infection. The physician would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent?
Obtain consent from the foster parents Rationale: Foster parents have the right to consent to medical care of minors in their care. The parents of a minor in foster care don't have authority to make decisions regarding his care. The nurse should call Child Protective Services only if she has concerns about a foster parent's authenticity. The nurse needn't notify the director of nursing unless complications occur.
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress note
A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?
Promoting adequate hydration
A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client?
Recognize and address the client's anxiety. Rationale: An early priority when admitting a client to a unit and establishing a relationship is to recognize and take steps to reduce anxiety. Assessing and addressing learning needs are important goals but should be addressed after the client has been settled on the unit. HIPAA should have been explained to the client earlier in her admission.
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.
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 registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O;) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?
Report back to the nurse immediately if any client has an output less than 240 mL.
A nurse is assigned to a client who is using an insulin pump. She has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?
Request information about nursing responsibilities in caring for a client with a pump.
A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data found in the accident victims would require immediate care?
Severe head injuries
A nurse has custody of a client's daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality?
Shred the documents or place them in a container to protect confidentiality
A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?
Supporting the client's emotional status
The charge nurse on the postpartum unit has received a report about a client who has just experienced a fetal demise and will be ready for transfer out of the labor unit in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take
Talk to the mother first and decide on a location that is mutually agreeable.
A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. What is the best response by the nurse overhearing the conversation?
Talk to the staff member privately about this.
A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status?
The RN communicates daily with the LPN about the condition of each resident. Rationale: It's within the scope of LPN practice to communicate with the physician; however, the RN should communicate daily with the LPN about the condition of each nursing home resident. The RN should be kept abreast of all changes in clients' conditions as they occur
The nurse recognizes that the goals established for a client's discharge are more likely to be accomplished when
The client assists in developing the goals
What should be charted by the nurse when the client has an involuntary commitment or formal admission status?
The client's receipt of information about status and rights should be charted
The nurse is observing a new graduate nurse instill eyedrops into a client's eyes. The nurse evaluates that the new graduate is using appropriate technique when which of the following steps is incorporated into the procedure?
The nurse's hand is stabilized on the client's forehead while instilling the drops.
Unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene?
The side rails on the head and foot of the bed are in the up position.
A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?
The student accepts a referral to a substance abuse counselor
A nurse is planning care for a hospitalized child who is 10 years of age, and is delegating care to a pediatric care assistant. When a nurse delegates a task to an unlicensed assistive personnel (UAP), which factor is most important?
The task is appropriate for that individual's preparation
A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. Who among the following is entitled to access client records?
Those directly involved in the client's care
A health care provider (HCP) is calling the pediatric unit and asking the nurse to go into the medical record for test results of a fellow pediatrician. How should the nurse respond to this request?
Verify that the caller is the HCP of record or has a need to know
A client diagnosed with thyroid cancer signed a living will that states he doesn't want ventilatory support if his condition deteriorates. As his condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best?
What exactly do you mean by wanting 'everything' done for you?"
A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?
Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.
The nurse has just received the change of shift report on the following clients on the labor, birth, recovery, and postpartum unit. Which of these clients should the nurse assess first?
a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia
The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN?
a 72-year-old client with diverticulitis Rationale: The client with diverticulitis will need care that the LPN should be able to provide safely. The client with angina is unstable and requires a registered nurse for continuous assessment. The client receiving chemotherapy treatment requires a registered nurse who is certified in chemotherapy administration. A child with Kawasaki's disease must be watched closely for cardiac complications, and it would be best to assign the child to an experienced pediatric nurse, not a new graduate.
When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be:
administering pain medication
The nurse receives report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving report?
an elderly client with pneumonia who is exhibiting periods of confusion
The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She's too upset by what is happening to make this decision." The nurse should:
ask the client to sign the consent form.
Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the charge nurse to change her assignment. She is frustrated because she has had to devote so much time and energy to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus. The charge nurse should:
offer to assist with the discharge teaching needs
A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which of the following documentation methods should the nurse suggest?
charting by exception
A Spanish-speaking client admitted with tuberculosis notes, through an interpreter, concerns about paying for needed medications. The nurse should:
collaborate with the social worker to investigate possible availability of funds
Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy?
compromised skin graft
A client needs to be transferred to the oncology unit for further care. Which of the following information is necessary to include in the transfer report?
current client assessment
A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for:
ensuring that the suspected child abuse is reported to local authorities
A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. The nurse should:
instruct the UAP that massage is contraindicated because it decreases blood flow to the area
A nurse discusses the HIV-positive status of a client with other colleagues. The client can sue the nurse for which of the following?
invasion of privacy
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances?
metabolic acidosis
Which of the following involves charting information about the client and client care in chronological order?
narrative charting
When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following?
nonmaleficence
In many institutions, which of the following telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?
orders for antibiotics
A bedridden client is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as:
0800 and 2000
The unlicensed assistive personnel (UAP) approaches the nurse and states, "The client does not know what caused him to be so depressed. He must not want to tell me because he does not trust me yet." In responding to this staff member, which statement by the nurse will help the UAP understand the client's illness?
"Endogenous depression is biochemical and is not caused by an outside stressor or problem. The client cannot tell you why he is depressed because he really does not know."
The client with acute mania has been admitted to the inpatient unit voluntarily. The nurse approaches the client with medication to be taken orally as prescribed by the health care provider (HCP). The client states, "I do not need that stuff." Which response by the nurse is best?
"The medication will help you feel calmer." Rationale: The nurse should first attempt a collaborative approach to increasing adherence to the prescribed medication regimen. Giving written medication information to a client with acute mania is poor nursing judgment because a client with acute mania cannot benefit from written information as a result of impaired ability to focus and concentrate. The client was a voluntary admission and has the right to refuse any medication. Giving the medication as an injection against the client's consent constitutes battery
A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse?
"We will continue to use antibiotics to treat the pneumonia."
When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort?
Acute pain
The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?
Assess the client's learning needs.
A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error?
Assess the patient for the medications' effects.
During a routine physical examination, a male client informs the nurse that he frequently participates in anal intercourse with his girlfriend. The nurse informs the client that:
Condoms are recommended for anal intercourse.
The son of a dying patient is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation?
Contact the chaplain to arrange a visit with the patient.
The nurse should enter the information on the medical record as a late entry with current date and time. The other options are incorrect because the nurse needs to document the care provided. Blank spaces should not be left in the chart and all care must be documented.
Enter the information tomorrow stating it is a late entry
Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when he or she reflects on the decision-making process and the role it will play in making future decisions?
Evaluating
A health care agency is applying for accreditation, and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include:
Evidence that nursing interventions have been evaluated in terms of the client's response.
A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics?
Fidelity
The nurse manager overhears comments made between two nurses. The first nurse repeatedly makes comments that focus on the second nurse's skin color and race. The second nurse is observably offended. Which of the following actions by the nurse manager to address the behavior of the first nurse would promote a quality practice environment?
Speak to the first nurse, pointing out that the comments constitute harassment and will not be tolerated.
A nurse is caring for a client with advanced heart failure. He can't care for himself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses his desire for "nature to take its course." The client's family is pleading with him to have a feeding tube inserted. What is the most appropriate action for the nurse to take?
Talk with the client's family about the client's right to decide for himself.
An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure?
The foster mother
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?
When communicating a change in a client's condition to his or her physician
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8° F (38.8° C). The nurse should:
promptly assess the client for potential perforation
The hospital is responding to a mass casualty disaster with adult and pediatric victims. After reallocating staff, the charge nurse on the pediatric floor should
review the census for clients that are candidates for early discharge.
After working multiple shifts in the psychiatric intensive care unit, a nurse recognizes that she's becoming more distant and, at times, even irritable. The best action for the nurse to take would be to:
talk with the charge nurse and seek support from her peers on the unit
Which finding is an expected outcome for an elderly client following treatment for bacterial pneumonia?
the ability to perform activities of daily living without dyspnea
A neonate requires surgical repair of a patent ductus arteriosus. The neonate's 16-year-old mother is present along with her parents, the neonate's grandparents. The neonate's mother states that she "isn't with the father anymore." The nurse must obtain informed consent for the surgery from:
the neonate's mother because she's considered an emancipated minor
The nurse on the orthopedic unit is going to lunch and is conducting a "hand-off" to the charge nurse. The goal of the "hand-off" communication is:
to provide accurate information about client's care to the next caregiver
An elderly client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When planning care for this client, the nurse understands that rehabilitation begins:
when the client is admitted to the hospital
A client recently diagnosed with hyperparathyroidism demands to see what the physician has written about him in the chart. What is the nurse's best response?
"I'll get the chart and set up a time for you to review it with your physician."
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 of the following would be the most appropriate response by the nurse to the surgeon?
"It is your responsibility to obtain informed consent from the client."
A community health nurse is working disaster relief immediately after a flood. Which of the following would be priority interventions following this crisis?
•Finding safe housing for the survivors. •Securing physical care. -Screening for waterborne diseases Rationale: The nurse would prioritize care according to Maslow's hierarchy of needs the nurse. Physical needs, safe housing, and prevention of disease would be the priority. Counseling would come after the physical needs were met. Vaccinations for childhood diseases would not be appropriate. The clients would need vaccinated for tetanus if not up to date.
A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?
•The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent.
A nurse is discussing principles in healthcare ethics with the nursing students. Which of the following would be an appropriate example of nonmaleficence?
•To protect clients from a chemically impaired practitioner. Rationale: Protecting clients from a chemically impaired practitioner is an appropriate example of nonmaleficence, which means to avoid doing harm, to remove from harm, and to prevent harm. Performing dressing changes to promote wound healing, providing emotional support to anxious clients, and administering pain medications to a client having pain are examples of beneficence, which means doing or promoting good.
When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply.
•that there was adequate disclosure of information •that the client understood the information •that there was voluntary consent on the client's part •that the client has full awareness of the potential complications
A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that his children work and no one has time to assist him with his self-care activities. The nurse should
Contact the nursing supervisor. Rationale: A nurse has a legal responsibility to report suspected abuse or neglect of an elderly client or a child. She must follow the chain of command and facility policies for reporting such suspicions. Notifying the family isn't the nurse's primary concern or responsibility. The police will be notified after the nurse has fulfilled the facility's policies.
A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply.
-Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. -Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours.
A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained?
"I wonder if there is any other way to prevent these bad rhythms." Rationale: The client wondering if there is another way to prevent the abnormal rhythms indicates that other treatment options weren't discussed with the client. Before participating in a clinical trial, the client must be informed of all other available treatment options. The other statements about implantable cardioverter-defibrillators are all true.
A public health nurse is responsible for contact tracing of individuals identified in confirmed cases of sexually transmitted infections. The nurse telephones an individual named by a client as a contact. The individual demands the name of the person who identified the individual as a contact. Which of the following is the most appropriate response from the nurse?
"Just as I will protect your privacy, I must protect the privacy of the other people involved."
The family of a hospitalized client demonstrates understanding of the teaching about legal documents related to end-of-life care such as "advance directive" and "power of attorney" when they make which statements? Select all that apply.
-"Advance directives give instructions about future medical care and treatment." -"If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." -"Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself."
The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first?
a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally
A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client's scalp. Which referral should the nurse make first?
a health care provider (HCP) Rationale: The client is exhibiting signs of hypothyroidism, which includes hair loss, pain, fatigue, and increased sensitivity to cold. Hypothyroidism may be impacting the client's mood, ability to concentrate, physical sensations, and energy levels. Resolving potential biological causes of her symptoms takes priority over rehabilitation strategies or psychological approaches.
The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse used to evaluate the effectiveness of such a program?
a reduction in the total number of restraint procedures
The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has:
severe abdominal pain. Rationale: A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency. An elevated pulse and confusion may occur for various reasons; the assistant should report all vital signs, but the severe pain must be brought to the nurse's attention immediately. Constipation will not require immediate intervention.
The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid
A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process?
"I will have the transplant coordinator speak with you to answer your questions." Rationale: The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.
A 14-year-old adolescent tells the nurse that she's in love with her 22-year-old neighbor and that they've had sex on several occasions. She doesn't want her parents to know because she loves him and is afraid they'll be angry. What is the nurse's best course of action?
Tell the adolescent that the law requires her to report the sexual contact because of the age difference Rationale: Although what a client says is considered privileged communication, there are exceptions when there's a risk of danger to the client or to another person. In this case, an adolescent is confiding that she's having sex with an adult, which is considered statutory rape even if the sex is consensual. The nurse must report this information to the proper authorities. It's inappropriate for the nurse to tell the adolescent that she'll speak only with the physician because the law requires the nurse to report this situation to the authorities. Although consulting with the charge nurse might be useful, doing so doesn't relieve the nurse of her duty to report the situation.
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain
