Hurst NCLEX RN Review - Safe and effective care environment

1. a client informs the nurse during the hospital admission assessment that the client does not have an advance directive, but designates the daughter to make Healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? Select all that apply.

A. Document the client's statement in the client's own words. B. Provide information on advance directives to the client. C. Inform the client that Personnel are available to assist with completing an advance directive if the client wishes to do so. D. The nurse inquiring about the client advance directive could cause the client anxiety and concern and should be avoided. Answer- a, b, and c The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and reassurance that there are Hospital Personnel to assist of completing the advance directive. the nurse should explain to the client that the law requires all kinds to be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client's wishes will be followed.A.

19. The case management nurse focuses on overseeing and organizing client care. Goals of the case management model of client care include__________ ( SATA) a. Providing cost-effective care to the client. B. Providing appropriate care to the client in a timely manner. C. Providing high-quality care to the client. D. Providing Healthcare Services to the client at no cost.

a, b, and c - the primary goals of case management are to provide high-quality, appropriate, and cost-effective care to each client in a timely manner. Every citizen is to have equal access to healthcare services, but it is not guaranteed to provide free healthcare. This is a common misunderstanding in some patients.

26. To Health Care Personnel are talking about a client by name in the facility elevator. Conversation is overheard by visitors in the same elevator. Which client right is violated? A. The client's right to review their medical records. B. The client's right to privacy. C. The client's right to have an advance directive. D. The client's right to refuse treatment

B. Healthcare information is privileged. The conversation between the healthcare Personnel in the elevator violates the client's right to privacy and could have subject the Personnel to liability

21. The role of case manager in client care is multifaceted and includes coordination of care among all Health Care Personnel involved in the care of a client during an episode of illness, from admission to recovery. Responsibilities of the case manager include - SATA A. Facilitating referrals for client care to members of the multidisciplinary healthcare Team. B. Supervising the client's discharge planning process. C. Providing direct nursing care to the client by the case management team. D. Providing the client and the client's family and caregivers with the appropriate information and resources to meet the client's needs and discharged from the health care facility.

a, b, and d - case management roles include facilitating referrals two members of the healthcare team, supervising the discharge planning process, and providing information and resources to the client and the client's family and caregiver.

11. The nurse sees that a new medication noted in a recent medication order is on The Client List of allergies. And the role of patient advocate what actions should the nurse take to ensure client safety? Select all that apply.

A.Document the medication with times and doses to be given, then administer the medication is ordered. B. Notify the physician immediately that the medication ordered is on The Client List of medication allergies. C. Discontinue the medication on the client's medication administration record. D. Check the client's allergy band against the list of client allergies documented in the medical record. Answer - b c and d. Administration of a medication that the client is allergic to could result in harm to the client. The Physician should be notified immediately, the medication should be discontinued on the medication administration record, and the client's allergy band should be checked against the list of allergies documented for accuracy.

27. A client ask to review the client's medical records. Which response made by the nurse is most appropriate? A. You will need to retain an attorney then have the attorney contact the medical records department in order to view your medical record. B. you may only view your medical records after you've been discharged from the health care facility. C. You have the right to review the medical records at that pertain to your care and have those records explained or interpreted if you feel it's necessary. D. Why do you want to view your medical records? Are you planning to file a lawsuit?

C. according to the patient's Bill of Rights the client has the right to View Medical Records pertaining to their care and have those records explained if necessary.

16. A client seen in the emergency department for a femur fracture is receiving discharge instructions forecast care, use of crutches, and follow-up care. The client complains of chest heaviness to the nurse. The nurse assures the client that the chest heaviness is probably caused by sore chest muscles from using the crutches, and instructs the client to sign the discharge instructions. The nurse neglects to document the complaints of chest heaviness nor does the nurse notify the physician. The nurse failed to implement which measure to intervene on the client's behalf? Select all that apply. A. Failure to preserve a client's privacy B. Failure to act as a client advocate C. Failure to take appropriate action. D. Failure to appropriately diagnose.

B & C - the nurse failed to act as an advocate by neglecting to take appropriate action regarding the clients symptoms, neglecting to document the symptoms, and failing to report the client's complaints to The Physician for further evaluation. The client's privacy is not an issue in this question, diagnosing is not the nurses scope of practice, but notifying the position of the client's complaints and symptoms is the nurses responsibility

22. A client's primary physician writes in order to prepare the client for discharge from the hospital the next day. The client expresses concern to the nurse about the ability to provide self-care and perform daily activities of living after arriving home from the hospital. Which member of the healthcare team should the nurse contact to provide information assist the client with resources for an effective discharge plan? A. The client's primary care physician who will coordinate care and resources for an effect of discharge plan individualized to the client's needs. B. The client's case manager who will coordinate care and provide information and resources for Effective discharge plan individualized to the client's needs. C. The client's physical therapist who will instruct the client to safely navigate the home environment after discharge. D. The clients occupational therapist, who are value at the client's ability to perform self care and activities of daily living.

B. The client's Health Care manager should be contacted regarding the order for discharge. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan

23. The responsibilities of a case manager are often performed by a nurse. A case manager may also be a - - - SATA A. Allied Health care provider. B. Social worker or patient Family Services care provider. C. Primary care physician. D. Primary care provider.

a, b, and d. - - A client's case manager can be a nurse, Allied Health care professional, social worker, or the client's primary care provider. The primary care physician generally does not assume the role of the client's case manager.

12. An elderly client from a long-term care facility arrives in the emergency department by ambulance with alter level of Consciousness. The Physician instructs the respiratory therapist to prepare for intubation. The nurse discovers a do not resuscitate bracelet on the client's risk during the initial assessment. Which immediate action should the nurse take to appropriately advocate for the client?

A. Assist with the respiratory therapist to prepare the client for immediate intubation. B. attempt to contact the client's family C. Notify the physician immediately of the clients DNR bracelet. D. Notify the dietitian immediately of the clients DNR bracelet. Answer - C . The nurse should immediately notify the physician upon discovering the clients DNR bracelet. reaching the client's family allows the family to be with the client to provide additional support, but this should be done after notifying the physician.

29. The nurse notices that a client's bedside privacy curtain has been left partially open during the clients bath. Which is the best action for the nurse to take to ensure the client's right to privacy? A. Inform the client that the curtain was left partially open in that the client may have been exposed at some point during the bath. B. Close the Privacy curtain to protect the client's right to privacy. C. No action is necessary. The client did not notice the open privacy curtain. D. No action is necessary. There are only a few visitors on the unit during this time of the morning.

B. The curtain should be closed as soon as the opening is noticed to protect the client's privacy. Informing the client that the curtain was open as embarrassing to the client and serves no purpose to the clients healing. The no action necessary options are incorrect

18. The nurse case manager knows case management is an example of which client care model? A. The outcomes evaluation model of Care. B. The protocol management model of Care. New Line. The interdisciplinary Care Management model. D. The risk assessment Care Management model.

C. Case management is an example of interdisciplinary Care Management model. Case management is the process of overseeing an organizing client care in collaboration with other organizations.

30. A prison inmate is brought to the emergency department with complaints of chest pressure that radiates up to the jaw and down the left arm. The nurse overhears another employee speaking rudely to the inmate client. Acting as the client's Advocate the nurse tells the employee privately that all clients are to be treated with equal respect and dignity. Which client right has the nurse protected? A. the right to free speech. B. The right to privacy. C. The right to considerate and respectful Care. D. The right to confidentiality.

C. Every client has the right to considerate and respectful care

20. The nurse knows that case management model of client care is - A. Implemented through a client's entire Hospital stay or episode of illness B. Implemented only during a client's acute phase of illness. C. Implemented if a client is unable to recover from an episode of illness within the expected time frame of the client's specific disease process. D. Focus on the cost of care delivered to the client.

a hyphen case management has implemented throughout a client's entire Hospital stay or episode of illness and focuses on the collaboration of all Healthcare Personnel involved in the care of the client

14. The nurse has a duty to act as a client Advocate. Failure to do so could result in possible _________. (Sata) a. Life-threatening complications for the client B. Legal action against the nurse and or Health Care Facility. C. Suspension of license or loss of License to the practicing nurse. D. Suspension of license or a loss of License to practice medicine.

a, b, c - the role of client Advocate is the nurses responsibility. Failure to act as the client Advocate could result and life-threatening complications, could expose the nurse to liability, potential legal action against the nurse and or the health care facility, and potential suspension or loss of License to practice nursing. Practicing medicine outside the scope of nursing could also result in life-threatening complications, legal action against the nurse and or health care facility, and potential suspension or a loss of license in practicing nursing. the answer would not be D, because a nurse does not have a license to practice medicine, online nursing.

6. a nurse is taking a client's medical history in the emergency room. The nurse asks if the client has an advance directive. The client responds by saying I have heard of advance directives but I do not have one. What is an advance directive? What is the nurses best response to the clients question?

a. An advance directive is a document that specifies your wishes regarding your personal effects and finances should you become an able to make the decisions. B. An advance directive is a document that specifies your wishes regarding healthcare and your finances should you become incapacitated. C. An advance directive is a document similar to a will, and specifies your wishes for burial should you die during hospitalization. D. An advance directive is a form of a living will. It specifies your wishes regarding health care and treatment options should you become incapacitated. Answer - advance directive is a legal document prepared by a competent individual that specifies What treatments the client desires should the client become incapacitated or unable to make a decision. it does not address the client's personal effects, finances, or burial wishes. These would be included in the last will and testament.

25. The nurse performs an admission assessment on a client who is directly admitted to the hospital from the physician's office. The client is worried and distracted, and explains to the nurse that because of the direct admission from the physician's office there was no preparation to be away from home. The client is concerned about the length of the stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? A. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There's a telephone here beside your bed so you can contact your family and friends. Is there anything I can do for you right now to help you? B. I know how you feel. I will be sure to tell your night shift nurse in shift report that you will probably need something to help you sleep tonight. C. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? You also have a telephone here at your bedside so you can contact family and friends. D. I can call your physician for you and asked if you could go home today, then schedule another date for your hospital admission.

a. - the case manager should be involved in coordinating the clients care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety.

8. Which statements are true regarding advance directives? Select all that apply.

a. Advance directives are used as guidelines for client treatment should the client's family deem them necessary. Be. Advance directives are legally binding documents. C. Advance directive should be placed in the client's medical record. D. Advance directive specify client's wishes for healthcare treatment should the client become incapacitated. Answer - b c and d. Advance directives are legally binding, should be placed in the client's medical record. The document details wishes for treatment should the client become an able to make informed Health Care decisions.

9. it is the nurses responsibility to act as client Advocate. What is the definition of client advocacy?

a. Advocacy is to inform the client to accept Medical Treatments that conflicts with the class phillipe's because Healthcare team knows what is best for the client. B. Advocacy is the act of arguing or negotiating on behalf of a particular issue, idea, or person. C. Advocacy is providing Assurance to the client that a surgical procedure will be successful and will achieve the desired outcome. D. Advocacy is informing the client that the client does not have the right to refuse medical treatment in certain circumstances. Answer - B. Advocacy is the act of arguing or negotiating on behalf of a particular issue, idea, or person. The nurse plays an important role as the clients advocate.

2. durable power of attorney for Health Care is an example of... SATA

a. An advance directive. B. A legal document that identifies a surrogate decision-maker for the client's financial matters in the event that the client becomes incapacitated. C. A legal document that identifies a surrogate decision-maker in the event the client becomes incapacitated or unable to make informed decisions. d. A legal document that becomes a permanent part of the client's medical record. Answer - a, c, d. Healthcare durable power of attorney is an example of an advance directive. Advance directives are documents signed by a competent person giving direction to healthcare providers about treatment choices. A durable power of attorney for Health Care is a legal document that identifies a surrogate decision-maker for Health Care decisions. The document becomes a permanent part of the client's medical record. A legal document that identifies a client surrogate for financial matters is incorrect because a durable power of attorney for Health Care identifies the decision maker for Health Care decisions only, this document does not designate a surrogate for financial matters.

7. Which documents are correctly identified as advance directives? Select all that apply.

a. Durable power of attorney for Health Care. B. Living Will C. Last will and testament. D. Clients Bill of Rights. Answer - A&B. Both the durable power of attorney for health care and the living will are examples of advance directives. Advance directives are documents prepared that specify the client wishes regarding health care treatments resuscitation and life support measures, and Life Care, and other specific wishes should the client become incapacitated in the future. the last will and testament goes into effect after the patient is deceased. The clients Bill of Rights outlines the rights of a client receiving medical treatment and is not an advance directive.

4. a disoriented client is admitted to the med-surg unit with a diagnosis of acute renal failure. The Physician orders a hemodialysis lying to be placed to facilitate acute hemodialysis. The client's spouse presents the nurse with an advance directive that gives instructions that no hemodialysis treatment be provided if the client becomes incapacitated and unable to make informed Healthcare decisions. What is the appropriate immediate action for the nurse to take at this time?

a. Inform the physician immediately of the advance directive and the client's wishes regarding no hemodialysis treatment. Place a copy of the advance directive in the client's medical record. B. Obtain consent from the client spouse for placement of a hemodialysis line. C. Inform the physician immediately of the advance directive in the client's wishes regarding no hemodialysis treatment. D. Tell the client spouse to speak with a physician in order to make an informed decision on whether or not to proceed with hemodialysis. Answer - a. The Physician should be informed immediately if orders conflict with the client's wishes. A copy of the advance directive should always be placed in the client's medical record. obtaining orders against the client's wishes is considered battery.

5. a client presents a durable power of attorney for Health Care designating the client's nice as the person to make Healthcare decisions for the client should the client become incapacitated and unable to make informed Healthcare decisions. The durable power of attorney identifies the nice as the...

a. Legal next of kin. B. Health Care proxy or surrogate decision-maker for Health Care issues only. C. Health Care proxy or surrogate decision-maker for healthcare and financial Issues. D. Person responsible for the clients hospital bill. Answer - B. A durable power of attorney for Health Care is an advance directive prepared by a competent individual designating a proxy or surrogate decision-maker should the client become incapacitated.

3. a client with a do not resuscitate - do not intubate order in the medical record becomes unresponsive and a code blue is called. The code team arrives and the physician is preparing to intubate the client. What action should the nurse take regarding the DNR - DNI order?

a. Prepare the client for immediate intubation. Assist the physician with the intubation procedure as needed. B. Immediately inform the physician and code team of the clients DNR order in the medical record. C. Assist the code team with the code blooper Advanced Care life support Protocol. D. Notify the physician in code team of the clients DNR order in the medical record, but the physician responding to the code blue will make the decision whether or not to intubate the client. Answer - B. It's the nurses responsibility to know the clients code status and the treatment wishes of the client when a DNR order is in effect. The nurse must communicate this information to other healthcare providers. Providing treatment to a client who desires no treatment is considered battery.

10. An intubated client admitted to the Intensive Care Unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. This is an example of the nurse acting as a client Advocate by...

a. Providing information to the client and fostering a sense of security. B. Promoting client privacy. C. Assuring client safety. d. Ensuring the client's wishes for treatment are followed. Answer - a. The nurse assesses a client Advocate by providing information to the client to alleviate fear and Foster a sense of security.

13. The client's physician orders a blood transfusion for a client whose hemoglobin level is 5.0. The nurse informs the client that blood will be drawn for a type and cross prior to the blood transfusion. The client avoids eye contact and then States I'm a Jehovah's Witness I thought that was in my chart. And quote the nurse demonstrates the role of client Advocate by which response to the client? A. Your hemoglobin is very low I can notify your physician to discuss with you how important it is for you to receive blood. B. I will place the information in your medical record. You have the right to refuse treatment which conflicts with your beliefs. Would you like to speak with your physician about other treatment options? C. Your physician ordered this blood transfusion because your hemoglobin is low you should do as you're physician recommends. D. Why do Jehovah's Witnesses choose not to receive blood transfusions?

answer - B, the nurse as Advocate supports the clients beliefs and treatment wishes.

17. The nurse knows that case management is- A. The process of managing the outcomes of client care by quality improvement measures and Improvement of the interdisciplinary Team. B. The process of client assessment in direct client care by the primary nurse, utilizing the nursing process and nursing diagnosis to guide delivery of Care. C. The process used by the healthcare facilities legal or Risk Management Department to evaluate legal claims filed against the facility or employees of the facility. D the process of overseeing and organizing client care in collaboration with the client's primary health care provider and Consulting physician

d - case management is the process of overseeing an organizing client care and collaboration with the client's primary care physician or healthcare provider, Consulting Physicians, and then ciliary care providers. The process of managing client care outcomes by quality improvement measures is a description of outcomes management. Client assessment and direct client care by the primary nurse is a description of bedside primary nursing. The process used to evaluate legal claims against the facility or its employees is a description of risk management.

15. A client is scheduled for open heart surgery the nurse enters the clients room to perform preoperative teaching and finds the client crying. The client states I really do not want to go through open heart surgery. I've told my children this, but they still want me to go through the surgery. I don't know what to do. And the quote what is the best response for the nurse as client advocate? A. Your children are correct. The open heart surgery is the best thing for your health. B. From what you're telling me you have some genuine concerns about your open heart surgery, and you feel your children are not addressing your concerns. You and your family will need to resolve this before going to surgery. See. I can contact your physician so you can discuss your concerns regarding the surgery. D. From what you're telling me you have some genuine concerns about the open heart surgery and you feel as if your children are not addressing your concerns. It's important to me in the healthcare team that we follow your wishes regarding surgery and treatment. Would you feel comfortable telling me more about your concerns?

d - the nurse has a duty to advocate for the client if there's a discrepancy in care. It's important to acknowledge the client's feelings and to demonstrate compassion and a willingness to understand. This presents an opportunity for additional communication.

28. A client's surgeon discusses the option of surgery and related benefits and risks with the client and the client's family. Which statement by the client demonstrates the client understands the right to make decisions regarding treatment and proposed plan of care? A. The surgeon says that I need this operation so I guess I'd better go ahead and have it Be. I am not so sure I want to have major surgery but my family will not even talk about other options. C. I'm afraid to tell my surgeon about my hesitation to have this operation. The surgeon will think I'm being foolish, so I didn't mention it. D. The surgeon explains the risk and benefits of the operation to me but the decision to have the surgery or to explore other treatment options is mine.

d. A client has the right to make decisions regarding recommended treatment options and the proposed plan of care. Ultimately the decision is the clients to make.

24. Case managers use clinical pathways in the process of evaluating and coordinating client care with the multidisciplinary team. A clinical pathway is - - A. A decision-making flowchart that uses the if-then method to address client responses to treatment. b. A set of practice guidelines developed by Professional Medical organization such as the Ana or American College of Surgeons. C a standardized set of pre-printed physician orders for client care which expedite the order process and can be customized to individual clients. D I said of practice guidelines based on specific client diagnosis which provides an overview for the disciplinary plan of care.

d.- a clinical pathway is a set of multidisciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care in to identify deviations from the plan of care.