Exam 4 PNC
The parents of an 8-year-old boy diagnosed with frostbite are distraught and state to the nurse, "We can't believe we didn't make our child come inside when he complained about his fingers being numb and hurting." How should the nurse respond?
"I can't imagine how you are feeling right now, but I'm sure you had no idea frostbite could happen. We will take good care of your son."
A client admitted with Hodgkin lymphoma has a handwritten prescription for vinblastine 3.7 mg intravenously (IV) weekly. The nurse interprets the prescription as vincristine 3.7 mg and administers the wrong medication. The client becomes neurovascularly compromised and has a fatal reaction to the medication. The client's family begins a lawsuit against the facility and the nurse's license is suspended by the board of nursing. In preparation for the lawsuit, the nurse meets with the nurse attorney to review the events. Which appropriate statement given by the nurse indicates he has an understanding of the lawsuit?
"I had a duty and it was my responsibility to get clarification before administering the medication, which I did not."
A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP?
"Your behavior in this situation is considered verbal abuse."
Which actions are examples of nursing actions listed in the ANA's Nursing: Scope and Standards of Practice for Standard 5: Implementation? Select all that apply.
-The nurse documents implementation and any modifications, including changes or omissions, of the identified plan. -The nurse utilizes community resources and systems to implement the plan. -The nurse utilizes evidence-based interventions and treatments specific to the diagnosis or problem.
After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that:
ANA aims at fostering high standards of nursing in the United States.
The new nurse is evaluating the effectiveness of the assigned nurse mentor. Which characteristic should the new nurse recognize as being inappropriate for the nurse mentor to role model?
Advising the new nurse to consult the nurse mentor before making decisions regarding client care
A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:
Aggressive
The nurse is caring for a parent of a 10-month-old infant. The parent is upset and states, "I have so many questions, but the doctor seems too busy to answer my questions." What is the best action by the nurse?
Assist the parent in preparing a list of questions for the health care provider's next visit.
Which behavior by the nurse is stereotyping?
Avoiding clients who are elderly because their care is time consuming.
A client is being seen in the mental health clinic because of relapse. The client has been nonadherent with the medication regimen. The nurse reinforces the advantages of taking medications. The nurse is using which ethical principle?
Beneficence
The instructor provides corrective information to the nursing student when the student refers to the client as the
COPDer in 216
A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing?
Caring for the same child from admission to discharge
Which method is reliable for identifying a preschooler before administering a medication?
Check the hospital identification bracelet.
A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?
Clinical nurse specialist
Which example of client care is not the responsibility of the nurse?
Confirming a medical diagnosis
A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs?
Consult reference materials to determine the normal vital signs for 1-month old infants.
A nurse is caring for a morbidly obese client who has undergone surgery for weight loss. The client reports pain 8/10 despite morphine sulfate 1 mg/hour continuous infusion being administered via a patient-controlled analgesia (PCA) pump. Which action will best protect the nurse from issues of liability?
Contact the health care provider with a request for a change in PCA
The nurse has a client who reminds the nurse of the nurse's sister, with whom the nurse has a close and positive relationship. This phenomenon is best characterized by which term?
Countertransference
The nurse has been unsuccessful in the psychiatric clinical placement and will be obliged to repeat it next semester. The criteria for passing or failing were based on the Psychiatric-Mental Health Nursing Scope and Standards of Practice, which are?
Descriptions of the responsibilities for which nurses are accountable
Which is one common mistake that people working in the helping professions do when applying theory to the therapeutic process?
Develop an overzealous commitment to one form of therapy, ignoring the benefits that other types of therapies may have for a given individual.
The nurse in charge of an inpatient psychiatric unit is irritated with a client who has borderline personality disorder. Which step should the nurse take?
Discuss the feelings with a colleague to promote coping.
Which is an important role for a nurse in the health care delivery system?
Identifying patient needs and working with patients to address them
A nurse overhears a colleague tell a client that based on the genetic testing results she should terminate the pregnancy. Which action is most appropriate for the nurse to take?
Immediately stop the nurse.
Which capability corresponds with home health care?
Improvises when providing care
A charge nurse informs a staff nurse of a new admission in active labor who is coming to the labor and delivery unit. The nurse is currently caring for a client in labor and another client who has a cesarean birth scheduled within the next half hour. How can the nurse best manage the client care assignment?
Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients.
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?
Mask is placed over nose and extends to bottom lip.
Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next?
No action is needed at this time because the drug level is normal.
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.
A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?
Notify the supervisor and provide care until another nurse can be assigned to the client.
Students are reviewing information about community health nursing. The students demonstrate understanding of the term "community-oriented nursing practice" by describing it as which of the following?
Nursing interventions that can promote wellness, reduce illness spread, and improve the health status of groups
Which measure should a home health care nurse integrate into routine practice to minimize the potential for lawsuits?
Perform thorough, accurate, and timely documentation.
A nurse caring for older adults in a long-term care facility is teaching a novice nurse characteristic behaviors of older adults. Which statement is not considered ageism?
Personality is not changed by chronologic aging.
The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone?
Record "T.O." at the end of the order.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?
Report the infection to an immediate supervisor
A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?
Seek research about the disorder.
A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not often performed wound care on a complex wound. Using effective intrapersonal communication, this nurse should:
Tell herself to "remain calm" and remember that she was trained to perform this skill.
A nurse and the facility have been named as defendants in a malpractice lawsuit. In addition to the nurse's attorney, whom else would be appropriate for the nurse to talk with about the case?
The agency's risk manager
The registered nurse (RN) has received orders to perform an unsafe practice on a client. The RN voices concern with the physician who gave the order, but the physician refuses to change the order. Whom should the nurse consult next regarding the order?
The charge nurse
It is important for home health care nurses to remember which point?
The nurse is the guest in the client's home.
Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution?
The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.
Nurses who value client advocacy follow what guideline?
They give priority to the good of the individual client rather than to the good of society in general.
A nurse saw a coworker steal drugs from a locked cabinet. The supervisor notices the missing drugs and has a good idea who is responsible for the theft. The supervisor asks if the nurse saw anything out of the ordinary. Which professional value reflects a nurse's duty to tell the truth?
Veracity
The nurse has drawn opioid pain medication into a syringe. When preparing to administer the medication, the client refuses, stating that pain is controlled currently at a level of 2 on a scale of 1 to 10. Which action should the nurse take to waste the medication?
Waste the medication with another nurse witness present.
Establishing the criteria for the education and licensure of nurses is a component of:
a state's nurse practice act.
A client with terminal breast cancer is being cared for by a long-time friend who is a physician. The client has identified her sister as the agent in her healthcare power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should
abide by the wishes of the sister who is the durable power of attorney agent.
In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene?
calling a security guard and another staff member for assistance
While working with an older male client, a nurse begins to think of the client as a grandfather and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?
countertransference
The nurse is demonstrating countertransference with a client with which behavior?
relating to the client because the client resembles a favorite cousin
The health care provider prescribes orders for a client with newly diagnosed uncontrolled seizure activity. When reviewing the prescriptions, the nurse correctly identifies that which prescription, if followed, puts him at risk for negligence charges?
restrain all 4 extremities
