LEADERSHIP AND MANAGEMENT ATI COMPREHENSIVE EXAM STUDYGUIDE!

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply

"An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." (CORRECT) 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." (CORRECT) 4. "A mass casualty event occurs if a fight between visitors occurs in the emergency department." (CORRECT) 5. "Mass casualty events may require the collaboration of many local agencies to handle the situation. RATIONALE: Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crises. This type of event can occur in the health care facility or outside of it. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe patient care.

The nurse is presenting a lecture on disasters and posttraumatic stress disorder (PTSD) to a group of new unlicensed assistive personnel (UAP). Which statements by the UAP indicate that teaching has been effective? Select all that apply.

"I will never experience PTSD." 2. "PTSD can potentially last a lifetime." (CORRECT) 3. "Clients can be easily startled and have difficulty sleeping." (CORRECT) 4. "Flashbacks occur, causing the client to relive the experience." (CORRECT) 5. "PTSD only occurs in clients who already have a history of depression." Rationale: Experiencing a traumatic event such as a disaster can produce both immediate and long-lasting psychosocial effects in people personally affected by the event. PTSD is a serious result of experiencing a traumatic event, and can potentially last a lifetime. Those with PTSD often report being easily startled and having trouble sleeping at night, which they didn't experience before the event. Clients will often report troubling flashbacks, which force them to relive the experience. PTSD can happen to anyone who experiences an extremely stressful event, and does not specifically occur in clients who have a history of depression.

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client tells the nurse that a lawyer has prepared a living will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a witness to sign the will and requests that the nurse act as a witness. Which is the appropriate nursing response to the client?

"I would be pleased to do that for you." 2. "You need to talk to the nursing supervisor." 3. "I never sign anything, and I need to refuse to do this too." 4. "A nurse caring for a client cannot serve as a witness to a living will." (CORRECT) RATIONALE: Living wills address the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as witnesses.

The nurse educator determines that a newly hired licensed practical nurse (LPN) in a local hospital demonstrates an accurate understanding of professional liability insurance when which statement is made?

"It is very expensive and not necessary." 2. "I should obtain my own malpractice insurance." (CORRECT) 3. "The hospital's liability insurance will cover my actions." 4. "The majority of suits are filed against health care providers and the hospital." RATIONALE: Nurses need their own liability insurance for protection against malpractice lawsuits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually when the nurse is sued, the employer is also sued for the nurse's actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.

A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization?

"It provides member services from a selected group of providers." 2. "It represents an arrangement between employers and insurance companies." 3. "Members can commonly elect to see any participating health care provider without prior authorization." 4. "Beneficiaries are limited to those providers that are participating health care providers for any required health care services." (CORRECT) RATIONALE: Options 1, 2, and 3 are accurate descriptions of the preferred provider organization. In the exclusive provider organization, beneficiaries are limited to those providers that are participating health care providers for any required health care services. If members elect to see health care providers outside the exclusive provider organization, services may not be covered

A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks the nurse if this document is still effective. Which is the most appropriate nursing response?

"Living wills may only be valid for 6 months." 2. "You will have to discuss the issue with your lawyer." 3. "Yes, it is effective until you make the decision to change it." 4. "A living will needs to be reviewed yearly with your health care provider." (CORRECT) RATIONALE: The client should discuss the living will with the health care provider, and it should be reviewed annually to ensure that it contains the client's present wishes and desires. Options 1 and 3 are inaccurate. Option 2 is not the most appropriate response.

The nurse is working with a 21-year-old client who has a family history of Huntington's disease and asks for information about the advantages of genetic testing. Which responses by the nurse is best? Select all that apply.

"No matter the result of the test, you will have peace of mind." 2. "Genetic testing will help you make decisions about having children." (CORRECT) 3. "Retirement issues might be easier to plan if you know the results of the test." (CORRECT) 4. "Knowing if you have the disease will allow you to make plans about your career." (CORRECT) 5. "Having this test will allow you to have 3 or 4 healthy years before symptoms begin." Rationale: Genetic testing can alert a client to a condition that may not be evident but that is certain to develop in the future. Huntington's disease is a degenerative neurological disease that affects cognitive, emotional, and physical function, but symptoms don't develop until an individual is 30 to 40 years of age; therefore, a 21-year-old client would have more than 3 to 4 years of symptom-free time. Testing is done to help an individual plan childbearing, career, and retirement. Also, there is no guarantee that the results of the test will bring peace of mind.

The nurse is planning the client assignments for the day. The assignment that the nurse communicates to the unlicensed assistive personnel (UAP) includes which clients? Select all that apply.

A 9-year-old client with cystic fibrosis who requires assistance with toileting (CORRECT) 2. A 5-year-old client admitted for diarrhea and dehydration who requires intravenous fluids 3. An 8-year-old client 2 hours post-tonsillectomy who requires frequent monitoring for hemorrhage 4. A 12-month-old client admitted 3 days ago with respiratory syncytial virus (RSV) who requires a bath (CORRECT) 5. A 10-month-old admitted for spasmodic laryngitis who is scheduled for discharge the following day who requires feeding (CORRECT) Rationale: The unlicensed assistive personnel (UAP) should be assigned clients who require basic care needs and are in stable condition. Therefore, the UAP should be assigned the 9-year-old client with cystic fibrosis who needs toileting assistance, the 12-month-old child with RSV who requires a bath, and the 10-month-old admitted for spasmodic laryngitis who requires feeding and is set to be discharged the following day and thus is stable. These clients are appropriate assignments because they are all stable with basic care needs. The client admitted with diarrhea and dehydration who requires IV fluids and the child just 2 hours post-tonsillectomy both require the licensed nurse because they are unstable clients who require care with nursing judgment.

The nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the accident. Which is accurate regarding the nurse's immunity from this suit?

A Good Samaritan law will protect the nurse. (CORRECT) 2. A Good Samaritan law will not protect the nurse. 3. A Good Samaritan law protects laypersons and not professional health care providers. 4. A Good Samaritan law will provide immunity from suit even if the nurse accepted compensation for the care provided. Rationale: A Good Samaritan law is passed by state legislators to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Its protection lies in preventing nurses or other health care providers from being sued for negligence in the care provided at the scene of the accident or during the emergency, even if further injury occurred because of the health care providers' care. Called immunity from suit, this protection usually applies only if all of the conditions of the law are met, such as if the health care provider receives no compensation for the care provided and if the care given is not willfully and wantonly negligent.

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

A client complaining of muscle aches, a headache, and malaise 2. A client who twisted her ankle when she fell while in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce (correct) RATIONALE: In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

A client on a ventilator (CORRECT) 2. A client in skeletal traction 3. A postoperative client preparing for discharge 4. A client admitted on the previous shift who has a diagnosis of gastroenteritis RATIONALE: The airway is always a priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities

The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel?

A client on strict bed rest and a 24-hour urine collection (correct) 2. A client scheduled to be transferred to the hospital for a cardiac catheterization 3. A client admitted to the center yesterday who had a below-the-knee amputation 4. A client scheduled to be discharged home following rehabilitation for a hip replacement procedure RATIONALE: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nurse practice acts and the job description of the employing agency. A newly admitted client who had a below-the-knee amputation will require physiological and psychosocial care and initiation of rehabilitation. A client scheduled to be discharged home will require reinforcement of home care management. A client scheduled for a cardiac catheterization requires physiological needs. The nursing assistant has been trained to care for a client on bed rest and on urine collections. The nurse should provide instructions to the nursing assistant regarding the tasks, but the task required for this client is within the role description of a nursing assistant.

The nurse is planning the client assignments for the day. Which is an appropriate assignment for the unlicensed assistive personnel (UAP)?

A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires a 24-hour urine collection (CORRECT) 4. A client who has difficulty swallowing food and fluids Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the appropriate assignment for a UAP would be to care for the client who requires urine collection. The client who has difficulty swallowing food and fluids is at risk for aspiration. Colostomy irrigations and tube feedings are not performed by unlicensed personnel.

A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign four clients and has a licensed practical nurse (LPN) and three unlicensed assistive personnel (UAP) on a nursing team. To which client should the nurse assign the LPN?

A client requiring frequent ambulation 2. The client requiring a 24-hour urine collection 3. An older adult client requiring assistance with a bed bath 4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours (CORRECT) Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine, assisting with frequent ambulation, and giving a bed bath can be done by a nursing assistant. The LPN is skilled in wound irrigations and dressing changes, and this client should be assigned to this staff member.

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client requiring twice daily dry dressing changes 2. A client requiring frequent ambulation with a walker (CORRECT) 3. A client on a bowel management program requiring rectal suppositories and a daily enema 4. A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures RATIONALE: Assignment of tasks needs to be implemented based on the job description of the UAP, the level of clinical competence, and state law. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse. Although a UAP may be trained to administer an enema (depending on the state practice act and agency policies), a rectal suppository needs to be administered by a licensed nurse. Option 2 is the most appropriate assignment for the UAP.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse collect data on first?

A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift (CORRECT) RATIONALE: Airway and breathing are always a high priority, and the nurse should attend to the client who had been experiencing a breathing problem first. The clients described in options 1, 2, and 3 would be intermediate priorities.

A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first?

A client who is ambulatory 2. A client with a fever who is diaphoretic and restless (CORRECT) 3. A client scheduled for physical therapy at 1:00 pm 4. A postoperative client who has just received pain medication Rationale: The LPN would plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. It is best to wait for pain medication to take effect before providing care to the postoperative client. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care.

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection (CORRECT) 2. A client who requires twice-daily dressing changes 3. A client who is on a bowel management program and requires rectal suppositories and a daily enema 4. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures RATIONALE: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. The assignment of tasks needs to be implemented on the basis of the job description of the individual, the individual's level of clinical competence, and state law. Options 2, 3, and 4 involve care that requires the skill of a licensed nurse. A UAP is not licensed

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires wound irrigation 2. A client who requires frequent ambulation (correct) 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization RATIONALE: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires frequent ambulation. The UAP is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

A nurse working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client should the nurse collect data on first?

A client who was complaining of severe back pain on the previous shift (CORRECT) 2. A client who is being moved to a different room and will need assistance packing 3. A client who is bed bound and needs to be turned and repositioned every 2 hours 4. A client who needs assistance dressing before transport to the dining room for breakfast RATIONALE: The nurse is working on a hospice unit, which means that the nurse is caring for the terminally ill client. The client who is terminally ill needs to be comforted, and the nurse must maintain a satisfactory lifestyle through the phase of dying. Although all of these clients need the nurse's attention, the client who needs to be seen first would be the client who was in severe pain on the previous shift. The nurse should evaluate this client to see if further pain medication is needed. Alleviating suffering is a priority nursing responsibility. Because pain is often an element of suffering, promoting optimal pain relief is a primary goal.

The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first?

A client with a diagnosis of ulcerative colitis who is scheduled to be discharged today 2. A client who was admitted during the night because of a severe exacerbation of asthma (CORRECT) 3. A client scheduled for a kidney, ureter, and bladder (KUB) x-ray to determine the location of a kidney stone 4. A client who had a pulmonary wedge resection 2 days ago and is attached to a closed chest tube drainage system RATIONALE: The nurse would first check the client who was admitted during the night because of a severe exacerbation of asthma. This client's problem directly relates to airway, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next check the client who had a pulmonary wedge resection 2 days ago and is attached to a closed chest tube drainage system. This client's problem also relates to airway; however, there is no indication that this client is experiencing any severe problems. The nurse would next assess the client scheduled for a KUB. The nurse would want to ensure that this client understands the reason for the x-ray. Additionally, the nurse needs to determine whether the client is experiencing any pain as a result of the kidney stone. The nurse would next assess the client preparing for discharge to determine the need for reinforcement of home care instructions.

The nurse has received the following client assignments. In which priority order should the clients be seen based on the clients' needs? Arrange the clients in the order that they should be seen. All options must be used.

A client with an arm cast for 1 day complaining of excruciating pain in the casted arm A client being transferred from the intensive care unit (ICU), 1 day post-coronary artery bypass graft surgery, complaining of incisional pain 2 A client being transferred from the intensive care unit (ICU), 1 day post-coronary artery bypass graft surgery, complaining of incisional pain A client admitted 4 days ago following a myocardial infarction (MI), complaining of a headache 3 A client admitted 4 days ago following a myocardial infarction (MI), complaining of a headache A client 1 day postoperative following an open reduction and internal fixation to the wrist, complaining of pain localized to the pin sites 4 A client 1 day postoperative following an open reduction and internal fixation to the wrist, complaining of pain localized to the pin sites A client who is 3 days postoperative abdominal surgery, complaining of pain when taking a deep breath 5 A client who is 3 days postoperative abdominal surgery, complaining of pain when taking a deep breath Rationale: Each of these clients is in pain and needs to be assessed and treated. The client with the excruciating pain needs to be assessed for compartment syndrome. Not treating this client could quickly result in a disability. Next, the new transfer should be assessed because this client underwent a major surgical procedure just 1 day before and is in pain. The client complaining of a headache needs to be assessed next to determine if hypertension could be the cause of the headache. A client with pain at the pin sites following an open reduction and internal fixation to the wrist has a priority need over the 3 day postoperative client experiencing pain when taking deep breaths.

The nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. What does the nurse determine is a characteristic of this type of nursing model practice?

A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used in providing client care. 3. Nursing personnel are led by an RN leader in providing care to a group of clients. (CORRECT) 4. A single registered nurse (RN) is responsible for providing nursing care to a group of clients. RATIONALE: In team nursing, nursing personnel are led by an RN leader to provide care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which is a characteristic of this type of nursing model of practice?

A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. (correct) 4. A single registered nurse is responsible for providing nursing care to a group of clients. RATIONALE: In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which victim should be transported to the hospital first?

A victim with a closed upper extremity fracture 2. A victim who is pulseless with fixed, dilated pupils 3. A victim with singed nasal and facial hair and difficulty breathing (CORRECT) 4. A victim with superficial lacerations on the lower extremities and begging for help Rationale: Singed nasal and facial hairs suggest the victim has inhaled a heated substance. In addition, the victim is experiencing respiratory difficulty and should receive treatment at the scene and then immediately be transported to the emergency department. Although closed fractures are serious, victims can wait for transportation after initial emergency management, such as immobilization. Minor soft tissue injuries are considered nonurgent and can wait for treatment. Fixed, dilated pupils in a pulseless victim indicate the victim is already deceased.

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

Accountability can be delegated." (CORRECT) 2. "It carries legal implications for task performance." 3. "One must answer for the care that one asks others to complete." 4. "It refers to the process of answering or being responsible for what occurs." RATIONALE: Accountability refers to the process of answering or being responsible for what occurs and carries legal implications for task performance. Accountability cannot be delegated; one must answer for the care given and for the care one asks others to complete.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies which aspect of care as a priority of care?

Actual or life-threatening concerns (CORRECT) 2. Completing care in a reasonable time frame 3. Time constraints related to the client's needs 4. Obtaining needed supplies to care for the client Rationale: Setting priorities means deciding which client needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns always are considered first. Although time constraints, obtaining needed supplies, and completing care in a reasonable time frame are components of time management, these items are not the priority in planning care for the client, based on the options provided.

The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?

Aggregate care prevention 2. The tertiary level of prevention (CORRECT) 3. The primary level of prevention 4. The secondary level of prevention RATIONALE: Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on seeking to detect existing health problems or trends and reducing the intensity and duration of the crisis during the crisis itself. There is no known aggregate care prevention level.

A client with a diagnosis of cystitis has an indwelling urinary catheter and is being cared for by an unlicensed assistive personnel (UAP). The nurse observes the UAP care for the client and intervenes if the UAP performs which action?

Allows the drainage tubing to rest under the leg (CORRECT) 2. Uses soap and water to cleanse the perineal area 3. Uses the drainage tubing port to obtain urine samples 4. Keeps the urinary drainage bag below the level of the bladder Rationale: Proper care of an indwelling catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, and, for the same reason, the drainage tubing is not placed under the client's leg. The tubing must drain freely at all times. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement.

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim should the nurse attend to first?

An alert victim who has numerous bruises on the arms and legs 2. A victim who received a head injury and is crying hysterically 3. A victim who sustained multiple serious injuries and is deceased 4. A victim with a partial amputation of a leg who is bleeding profusely (CORRECT) RATIONALE: The nurse determines which victim will be attended to first based on the acuity level of the victims involved in the disaster. The victim who must be treated immediately or life, limb, or vision will be threatened is categorized as emergent and is the priority (option 4). The victim who requires treatment, but life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority (option 2). If the victim requires evaluation and possible treatment, but time is not a critical factor, then that person is categorized as nonurgent and is the third priority (option 1). In such a disaster, the victim who sustained multiple serious injuries and is deceased is not the priority.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

Any available room near the elevator 2. Room farthest from the nurses' station 3. Private room within sight of the nurses' station (CORRECT) 4. First available room across from the nurses' station RATIONALE: A quiet room in which stimuli can be minimized is most important, and so a private room within sight of the nurses' station is the correct option. The client will require constant monitoring, so the room farthest from the nurses' station is inappropriate. From the remaining options, rooms across from the elevator and the nurses' station have a high traffic flow and noise and would therefore be inappropriate.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift (correct) 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift RATIONALE: The nursing hands-off (end-of-shift) report needs to be an efficient and accurate account of the client's condition during the last shift. It needs to include pertinent information about the client, such as tests and treatments; as-needed medications given or therapies performed during the past 24 hours, including the client's response to them; changes in the client's condition; scheduled tests and treatments; current problems; and any other special concerns. It is not necessary to include the total number of medications given or a list of all the tests and treatments that the client has had since admission. Only significant vital signs need to be included.

The nurse is assisting in caring for a client with a head injury who is restless and is pulling at the intravenous (IV) line. The client's health care provider does not want to sedate the client, and the family has requested that the client not be restrained. The nurse should implement which?

Ask a family member to sit with the client. 2. Ask a unlicensed assistive personnel (UAP) to monitor the client. 3. Stay with the client and consult with the nurse manager about the situation. (CORRECT) 4. Tell the family that the application of wrist restraints is critical to prevent injury to the client. RATIONALE: The nurse must stay with the client and consult with the nurse manager about the situation. It may be necessary for the nurse manager to contact the supervisor to obtain an additional staff member to care for the client. Because the client has a head injury, a major concern is the development of increased intracranial pressure (ICP). The application of restraints may agitate the client, causing further restlessness and thus increasing ICP. A UAP is not trained to monitor for increased ICP. It is inappropriate to ask a family member to sit with the client.

An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected, and emergency surgery is required immediately in order to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse plans to take which best nursing action?

Ask the hospital chaplain to sign the consent form. 2. Transport the client to the operating room immediately. (CORRECT) 3. Call the nursing supervisor to initiate a court order for the surgical procedure. 4. Call a family member to obtain telephone consent before the surgical procedure. RATIONALE: Generally in only two instances is the informed consent of an adult client not needed. One instance is during an emergency in which delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent.

The nurse is caring for a client who is receiving intramuscular antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. With which crime can the client legally charge the nurse as a result of the nursing action?

Assault 2. Battery (CORRECT) 3. Negligence 4. Invasion of privacy RATIONALE: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. Invasion of privacy occurs when the individual's private affairs are unreasonably intruded. In this situation, the nurse can be charged with battery because the nurse administered a medication that the client refused.

The nurse is caring for a client who has refused to take an oral medication. The nurse tells the client that the nurse will hold the client down and give the medication by injection if the client doesn't take the oral medication. The nurse then takes the client's bathrobe so the client will have to remain in his room. Which intentional torts has this nurse committed? Select all that apply.

Assault (CORRECT) 2. Battery 3. False imprisonment (CORRECT) 4. Invasion of privacy 5. Defamation of character Rationale: The nurse has assaulted or threatened the client with an injection. The nurse did not touch the client without consent, so there was no battery. The nurse forced the client to stay in the room, which is false imprisonment, but the nurse did not invade the client's privacy nor did the nurse defame (publish false statements about) the client's character.

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?

Assault (correct) 2. Battery 3. Negligence 4. Invasion of privacy RATIONALE: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. When the individual's private affairs are unreasonably intruded upon, invasion of privacy occurs.

The nurse is employed in a long-term care facility as a charge nurse of the night shift. The nurse determines that as a charge nurse, authority appropriately refers to which explanation?

Being responsible for what the staff members do 2. Accepting the responsibility for the actions of others 3. Carrying the legal responsibility for the task performance of others 4. The official power to approve an action, command an action, or to see that a decision is enforced (CORRECT) RATIONALE: Authority refers to the official power an individual has to approve an action, to command an action, or to see that a decision is enforced. Options 1, 2, and 3 are not related to the description of a position of authority.

A group of nurses are reinforcing instructions on health and safety management to survivors of a hurricane before they leave their temporary shelter and return home. Which instructions should the nurses include? Select all that apply.

Boil water for 5 to 10 minutes before drinking. (CORRECT) 2. Wash hands with soap and water frequently. (CORRECT) 3. Avoid mixing chemicals such as cleaning chemicals. (CORRECT) 4. Avoid using any water always, for any use in the aftermath of a disaster. 5. Add 10 to 20 drops of chlorine bleach to a gallon of water before drinking. (CORRECT) Rationale: The American Red Cross often provides temporary shelters for those who have been displaced during a disaster. It is a priority that nurses teach survivors about safety measures before they return to their homes. The nurse should teach the client that water can be used but that special measures need to be taken before use. The nurse should teach the survivors to avoid mixing chemicals such as cleaning chemicals together to prevent the formation of a toxic gas. Water needs to be boiled for 5 to 10 minutes before drinking to prevent ingestion of a harmful organism. Hands need to be washed frequently with soap and water to prevent disease transmission. In addition, 10 to 20 drops of chlorine bleach can be added to a gallon of water to make it safe for drinking.

Which are the best ways for the nurse to avoid malpractice? Select all that apply

Bring gifts to each client. 2. Perform interventions in a timely manner. (CORRECT) 3. Provide the same care to each and every client. 4. Document assessments and procedures completed. (CORRECT) 5. Know current nursing literature in their area of practice. (CORRECT) Rationale: The nurse can avoid malpractice by developing a caring rapport (not bringing gifts) with the client and documenting assessments, interventions, and evaluations completely and in a timely manner. Nurses should also know current nursing literature in their area of practice.

Which factors should the nurse consider when developing a critical incident stress debriefing (CISD) plan for employees of a level 1 trauma center? Select all that apply.

CISD promotes effective coping strategies. (CORRECT) 2. CISD occurs in small group settings for staff. (CORRECT) 3. CISD can often exacerbate the stress response. 4. CISD may help prevent posttraumatic stress disorder. (CORRECT) 5. CISD is only one component of a much larger stress management program. (CORRECT) Rationale: Critical incident stress debriefing (CISD) is only one component of a much broader critical incident stress management program. The nurse should consider the benefits of CISD when creating a plan, which includes talking and expressing feelings about an event in a safe and calm setting. Health care professionals are exposed to stressful incidents on a daily basis. CISD promotes effective coping strategies, occurs in small group settings, and is part of a much larger stress management program. Lack of debriefing can lead to posttraumatic stress disorder. CISD does bot exacerbate the stress response or make symptoms worse, but rather helps alleviate the stress through talking in a calm environment.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. Which action would be the appropriate initial action by the nurse?

Call security. 2. Report to a coworker. 3. Call the Board of Nursing. 4. Call the nursing supervisor. (CORRECT) RATIONALE: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities as required. Option 2 is not the appropriate action. Option 3 is not an initial action. Security may be called if a disturbance occurs, but no data in the question support this. Therefore, this is not the appropriate initial action.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent. (CORRECT) RATIONALE: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate

The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest to use?

Case finding in the school to identify dietary practices 2. School screening programs for early detection of children with poor eating habits 3. Conducting a community-wide dietary screening activity to detect community dietary trends 4. Providing educational programs, literature, and posters to promote awareness of healthy eating (CORRECT) RATIONALE: Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring. Options 1, 2, and 3 are secondary prevention measures that seek to detect existing health problems or trends.

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply

Change the password for entering computer files at least monthly. (correct) 2. Shred the printout of the nurse's flowchart at the end of the nurse's shift. (correct) 3. Use own user name and password when logging into the computer system. (correct) 4. Leave the computer terminal immediately after logging in to check on the status of a client. 5. Sign on another nurse to your account as long as the other nurse is not supplied with user name and password. RATIONALE: Computer terminals should never be left unattended after the nurse has logged on. This could allow unauthorized users to access the personal information of clients, and it represents a breach of confidentiality and security of client records. Likewise, another user should never be allowed access to one's account. Changing the password for computer entry monthly, shredding the printout of the nurse's flowchart, and using only personal user names and passwords represent actions that are acceptable ways to protect client information.

The nurse is caring for a client who just returned from surgery for repair of a fractured arm. The client complains of severe pain in the arm and also that his hand is feeling numb. The nurse notes that the client's fingers are pale and that the pulse in his arm is very weak. The nurse attempts to contact the surgeon numerous times, but the surgeon does not return the call. Who should the nurse notify at this time? Select all that apply.

Charge nurse (correct) 2. Hospital supervisor (correct) 3. Hospital administrator 4. Surgeon's supervisor (correct) 5. Local media representative Rationale: The nurse has a duty to find assistance for this client even if the client's health care provider does not respond. The nurse would immediately notify the charge nurse, the hospital supervisor, and the surgeon's supervisor or another surgeon that the charge nurse directed the nurse to call. It would not be necessary to notify the hospital administrator at this time and the nurse would never notify local media about the client's condition.

The nurse reviews the nursing care plan developed by a nursing student caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. The nurse intervenes if the student documents which intervention in the plan?

Check the residual every 4 hours. 2. Check for placement every 4 hours. 3. Check for placement before administering medications through the tube. 4. Keep the feeding bag filled with at least 100 mL of feeding continuously so that it does not run dry. (CORRECT) RATIONALE: The placement of an NG feeding tube is checked at least every 4 hours for residual during administration of continuous tube feedings. Placement is also checked before each bolus with intermittent feedings and before the administration of medications through the tube. The bag and tubing are completely changed every 24 hours or per agency protocol. The hanging bag should be rinsed before new formula is added to it. An excess amount of formula should not be allowed to sit in the feeding bag because of the potential for the growth of bacteria.

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?

Clear breath sounds in a client with heart failure 2. A postoperative client who develops a cough and a fever(CORRECT) 3. The absence of a wound infection in a client who had a coronary artery bypass graft 4. A client with diabetes mellitus demonstrating accurate use of a glucometer after teaching RATIONALE: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of factors. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken. A postoperative client who develops a cough and a fever identifies a negative outcome.

The nurse knows that litigation involving nurses is common because of which reasons? Select all that apply.

Clients are better educated about health care. (CORRECT) 2. Clients are better informed about their rights. (CORRECT) 3. Clients do not trust nurses and health care providers. 4. Clients have a higher expectation about the care they receive. (CORRECT) 5. Clients are aware that lawsuits result in payment of large sums of money. Rationale: The reasons that health care-related litigation involving nurses is common is because clients are more educated, more aware of their rights, and have a higher expectation regarding the care they receive. Lawsuits involving nurses are not common because of an expectation of monetary gain or because nurses are not trusted.

A client in labor is experiencing dystocia. In delivering care to this client, the nurse should place the highest priority on which ongoing nursing interventions?

Coaching and supporting breathing techniques 2. Monitoring of the status of both mother and fetus (CORRECT) 3. Educating and updating family members about the progress of labor 4. Providing comfort measures, change of position, emotional support, and touch RATIONALE: All of the options represent correct nursing actions, but the highest priority is to monitor the status of the mother and fetus. This option is the one that exemplifies the most urgent physiological need and, as such, takes precedence over the other nursing interventions.

The nurse is assigned to care for a newly admitted client and is reviewing the health care provider's prescriptions. The nurse notes that the health care provider has prescribed a medication dose that is twice the amount that the client reports taking before admission. Which nursing action is appropriate?

Consult with the registered nurse (RN). (CORRECT) 2. Administer the medication as prescribed. 3. Administer half of the prescribed dose and then notify the RN. 4. Question the client regarding the accuracy of the reported dosage. Rationale: If the nurse determines that a health care provider's prescription is unclear or if the nurse has a question about a prescription, the nurse should consult with the RN, who will then contact the health care provider before implementing the prescription. Under no circumstances should the nurse carry out the prescription unless the prescription is clarified. Questioning the client regarding the accuracy of the dosage of the medication may seem like a viable option, but this action also may cause the client to become upset. The nurse would not administer the medication, nor would the nurse administer an altered dosage.

The nurse employed in a long-term care facility calls the health care provider (HCP) regarding a new medication prescription because the dose prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?

Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the HCP can be contacted. 4. Administer the recommended dose but continue to locate the HCP. RATIONALE: If the HCP writes a prescription that requires clarification, it is the nurse's responsibility to contact the HCP for clarification. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until clarification has been obtained.

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which would be the initial action by the nurse who observed the error?

Contact the supervisor. 2. Complete an incident report. 3. Document the error in the client's record. 4. Ask the nurse if he or she intends to report the error. (CORRECT) RATIONALE: The initial action by the nurse who observed the error would be to ask the nurse if he or she intends to report the error. To ensure client safety, all errors need to be reported. The client also needs to be assessed immediately. An incident report needs to be completed by the nurse who administered the incorrect medication. The appropriate documentation also needs to be made in the client's record by the nurse who administered the incorrect medication. If the nurse who made the error indicates that the error will not be reported, then it may be necessary to contact the supervisor.

A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago at 7:30 am. The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 and is due to eat lunch at noon. List in order of priority the actions that the nurse should take. Arrange the actions in the order that they should be performed. All options must be used.

Correct Answers: Your Answers: Check the client's blood glucose level. 1 Check the client's blood glucose level. Give the client half a cup of fruit juice to drink. 2 Give the client half a cup of fruit juice to drink. Take the client's vital signs. 3 Take the client's vital signs. Retest the client's blood glucose level. 4 Retest the client's blood glucose level. Give the client a small snack of carbohydrate and protein. 5 Give the client a small snack of carbohydrate and protein. Document the client's complaints, the actions taken, and the outcome. 6 Document the client's complaints, the actions taken, and the outcome. Rationale: The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first would check the client's blood glucose level to verify that the client is experiencing hypoglycemia. After this is verified, the nurse would give the client 10 to 15 g of carbohydrates and then retest the blood glucose level in 15 minutes. In the meantime, the nurse would check the client's vital signs. The nurse would give the client another food item containing 10 to 15 g of carbohydrate if the client's symptoms do not resolve. Otherwise, the nurse would provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than an hour away from the time of the occurrence. After treatment and the resolution of the hypoglycemic event, the nurse would document the occurrence, the actions taken, and the outcome.

The nurse on the day shift is assigned to care for the following six clients. List in order of priority how the nurse should plan to check the assigned clients. Arrange the actions in the order that they should be performed. All options must be used.

Correct Answers: Your Answers: Client who has a tracheostomy and is on a mechanical ventilator 1 Client who has a tracheostomy and is on a mechanical ventilator Client who requires before-breakfast insulin 2 Client who requires before-breakfast insulin Client who is scheduled for a cardiac catheterization at 9:00 am 3 Client who is scheduled for a cardiac catheterization at 9:00 am Client who requires medications at 10:00 am 4 Client who requires medications at 10:00 am Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home 5 Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home Client who is scheduled for physical therapy in the afternoon 6 Client who is scheduled for physical therapy in the afternoon Rationale: The airway is always a high priority, and the nurse first assesses the client who has a tracheostomy and is on a mechanical ventilator. The remaining order of priority is guided by time guidelines. Therefore, the nurse next administers before-breakfast insulin, assesses the client who is scheduled for a cardiac catheterization at 9:00 am, and then administers medications scheduled for 10:00 am. Finally, the nurse checks the client who is scheduled for discharge, and this is followed by checking the client who is scheduled for physical therapy in the afternoon.

Which guidelines should the nurse follow when performing narrative documentation? Select all that apply

Date and time entries. 2. Sign and title each entry. 3. Avoid judgmental and evaluative statements. 4. Document judgmental information completely. 5. Do not leave blank spaces on documentation forms. RATIONALE: The nurse always dates and times entries and signs and titles each entry. The nurse provides objective, factual, and complete documentation and avoids subjective, judgmental, and evaluative statements. Quotes are used to relate what the client actually said. The nurse avoids leaving blank spaces on documentation forms because this allows for an area in which notes can be entered by others at a later time. The recording of information in the client's record must be sequential.

The licensed practical nurse is considering leaving the nursing profession after caring for multiple clients who have been diagnosed with conditions that have poor outcomes. Which measures would most likely assist the nurse in relieving this distress? Select all that apply.

Decrease opportunities for multidisciplinary rounds. 2. Share the frustrations at unit multidisciplinary meetings. (CORRECT) 3. Tell stories about the experiences with other professionals. 4. Participate in continuing education that is restricted to nurses. 5. Engage in ethics discussions with both nurses and other health care practitioners. (CORRECT) Rationale: Moral distress is a shared experience with both nurses and health care practitioners and efforts to alleviate this distress are most successful when the efforts are also shared.

The nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to an unlicensed assistive personnel (UAP) to attend to the other clients and tells another nurse to call the health care provider immediately. In this situation, the nurse is implementing which leadership style?

Democratic 2. Situational 3. Autocratic (CORRECT) 4. Laissez-faire RATIONALE: Autocratic leadership, also called "directive leadership," involves the leader in assuming complete control over the decisions and activities of the group. In this situation, the nurse assumed the autocratic style of leadership so that all necessary tasks would be accomplished immediately. Democratic leadership, also called "participative leadership," is characterized by a sense of equality among the leader and other participants. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Laissez-faire is a permissive style of leadership in which the leader gives up control and delegates all decision making to the work group.

When caring for clients, the nurse knows that which ethical philosophies focus on understanding relationships and the use of personal narratives? Select all that apply.

Deontology 2. Utilitarianism 3. Ethics of care (CORRECT) 4. Feminist ethics (CORRECT) 5. Consensus in bioethics Rationale: The ethics of care and feminist ethics both promote a philosophy that focuses on understanding relationships, especially personal narratives. Deontology defines actions as right or wrong based on their "right-making characteristics," which include fidelity to promises, truthfulness, and justice. Utilitarianism is a system of ethics that a value is determined by its usefulness. Consensus in bioethics is unrelated to the information in the question.

Place in correct order the steps the nurse should use to resolve an ethical dilemma. Arrange the actions in the order that they should be performed. All options must be used.

Determine if an ethical dilemma exists. Gather necessary information. 2 Gather necessary information. Clarify values. 3 Clarify values. Verbalize the problem. 4 Verbalize the problem. Identify possible courses of action. 5 Identify possible courses of action. Negotiate a plan. 6 Negotiate a plan. Evaluate the plan. 7 Evaluate the plan. Rationale: The key steps in the resolution of an ethical dilemma are to determine if an issue is an ethical dilemma, gather information relevant to the case, clarify values, verbalize the problem, identify possible courses of action, negotiate a plan, and evaluate the plan over time.

Following an airplane crash that had only a few survivors, the nurse should anticipate which survivor responses to stress? Select all that apply.

Difficulty sleeping (CORRECT) 2. Feeling vulnerable (CORRECT) 3. Feeling blame or guilt (CORRECT) 4. Feeling numb or in disbelief (CORRECT) 5. Being unaffected by the crash Rationale: Experiencing a disaster can produce both immediate and long-lasting psychosocial effects in the survivors. Coping abilities in the survivors in response to the stress can lead to many different responses. Often survivors will have difficulty sleeping, feel vulnerable that the event could happen again, experience blame for the event and guilt that they survived, or even feel numb or in disbelief that the event happened. Seldom are survivors completely unaffected by a disaster.

The nurse is assisting in developing a plan of action for the emergency department in the event of an internal fire. Which should the nurse include in the plan? Select all that apply.

Direct ambulating clients to walk to a safe location. (CORRECT) 2. Continue oxygen for all clients to reduce damage to lung tissue. 3. Wait for the fire department to arrive before initiating the plan of action. 4. Remove all clients from danger before attempting to extinguish the fire. (CORRECT) 5. Move bedridden clients away from the fire area by use of beds or stretchers. (CORRECT) Rationale: The nurse has many roles in responding to fires in the health care facility. The nurse should remove all clients and visitors away from the fire. Ambulating clients should be directed towards a safe location, while beds or stretchers can be used to move bedridden clients. Oxygen is considered flammable; therefore, all clients who can breathe without oxygen should not use it. The nurse should not wait for the fire department to arrive, but rather should act immediately to protect clients from harm.

The nurse is preparing to administer medications to an assigned client and notes that the prescription for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the health care provider to clarify the prescription and asks the health care provider to prescribe a dosage within the recommended range. The health care provider refuses to change the prescription and instructs the nurse to administer the dose as prescribed. Which action should the nurse take?

Discontinue the prescription. 2. Contact the nursing supervisor. (CORRECT) 3. Administer the dose as prescribed. 4. Call the state medical board and report the health care provider. RATIONALE: If the health care provider writes a prescription that requires clarification, the nurse's responsibility is to contact the health care provider for clarification. If there is no resolution regarding the prescription because the prescription remains as it was written after talking with the health care provider or because the health care provider cannot be located, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until clarification is obtained. Option 1 is not within the scope of nursing practice. Option 4 is a premature action.

The nurse observes an outburst by a client with a history of schizophrenia, during which the client uses extreme foul language. Which appropriate documentation should the nurse make for this occurrence?

Document that the client is swearing loudly. 2. Document that the client is having an outburst. 3. Use quotation marks, placing dashes and lines in the place of the profane words. 4. Use quotation marks, exact words, and additional objective information about affect and nonverbal behavior. (correct) RATIONALE: Option 4 provides accurate, legally defensible information regarding the client's behavior. Options 1 and 2 are not objective. Option 3 is incomplete documentation and is not legally defensible.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of the tasks?

Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task. (correct) RATIONALE: The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom?

Each employee 2. All members of the organization 3. A few individuals such as the board of directors (CORRECT) 4. Many individuals filtering down to the individual employee RATIONALES: With regard to the decision-making process, organizations may be described as having a centralized or decentralized structure. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals. Conversely, when the decision making involves a number of individuals and filters down to the individual employee, the organization is said to operate in a decentralized fashion.

The nurse has been asked to serve on the health care facility ethics committee and knows that this committee serves which purposes? Select all that apply.

Education (CORRECT) 2. Case consultation (CORRECT) 3. Caring for aging clients 4. Process ethical dilemmas (CORRECT) 5. Approve emergency mental health commitment Rationale: The purposes of an ethics committee include processing ethical dilemmas, providing education, and providing policy recommendations and case consultations. An ethics committee would not provide care for aging clients or approve emergency mental health commitment.

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?

Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. (CORRECT) RATIONALE: The nurse is responsible for the care provided to the assigned clients. The appropriate action is to provide safety to the client that is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP.

The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which is accurate regarding immunity from this suit?

Good Samaritan laws will protect the nurse. 2. Good Samaritan laws protect laypersons and not professional health care providers. 3. Good Samaritan laws will protect the nurse if the care given at the scene was not negligent. 4. Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided. (CORRECT) RATIONALE: A Good Samaritan law is passed by a state legislature to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called "immunity from suit," this protection usually applies only if all the conditions of the law are met; for example, the health care provider receives no compensation for the care provided, and the care given is not willfully or wantonly negligent.

A 7-year-old child is admitted to the pediatric unit with acute exacerbation of asthma due to infection. The health care provider has written the following prescriptions. In which priority order should the nurse implement the prescriptions? Arrange the actions in the order that they should be performed. All options must be used.

High-Fowler's position O2 via nasal cannula at 2 L/min 2 O2 via nasal cannula at 2 L/min Erythromycin ethylsuccinate (EryPed) 3 Erythromycin ethylsuccinate (EryPed) 200 mg orally every 6 hours 4 200 mg orally every 6 hours Chest x-ray 5 Chest x-ray Clear liquids PO as tolerated 6 Clear liquids PO as tolerated RATIONALE: Placing the child in high-Fowler's position first will assist in breathing. The oxygen can then be applied. Administering the antibiotic is the next priority. The chest x-ray should not be done until the child has had oxygen and the first dose of the antibiotic. The clear liquid diet is the last task to be performed.

The nurse manager asks a licensed practical nurse to work on her day off because of a short-staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. Which response by the licensed practical nurse to the nurse manager is assertive?

I can't work that day." 2. "You know how I hate to work extra shifts." 3. "I will if you need me but I might be a few minutes late." 4. "I have planned to take the day off and will not be able to work on that day." (CORRECT) RATIONALE: The most assertive response is the one that is direct and conveys a clear message in a positive manner. Option 1 is a passive response. Option 2 is an aggressive response. Option 3 is a passive-aggressive response.

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

I have a legal obligation to report this type of abuse." (CORRECT) 2. "I promise I won't tell anyone, but let's see what we can do about this." 3. "Let's talk about ways that will prevent your daughter from hitting you." 4. "This should not be happening. If it happens again, you must call the emergency department." RATIONALE: Confidential issues are not to be discussed with nonmedical personnel or with the client's family or friends without the client's permission. Clients should be assured that information is kept confidential unless it places the nurse under a legal obligation. The nurse must report situations related to child, older adult abuse, and other types of abuse, depending on state laws; gunshot wounds; stabbings; and certain infectious diseases.

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response to the client is appropriate?

I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request." (CORRECT) Rationale: Living wills are required to be in writing and signed by the client. The client's signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including the nurse of a facility where the declaring is receiving care, from being a witness. Option 2 is not therapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

The nurse wants to ensure that the emergency department is prepared for a disaster and is creating an action plan for educating the staff. Which actions should the nurse plan in order to adequately prepare the staff? Select all that apply.

Identify specific nursing roles during a disaster. (CORRECT) 2. Test the disaster plans before a disaster occurs. (CORRECT) 3. Begin educating staff on roles at the time of a disaster. (CORRECT) 4. Encourage each nurse to create a personal emergency preparedness plan. (CORRECT) 5. Create a quick action plan for the emergency department when a disaster occurs. Rationale: Disasters can happen at any time, without warning. Therefore, it is important that health care facilities have a plan in place. In order to adequately prepare staff for a disaster, the nurse manager should identify specific nursing roles, begin educating staff on what is expected of them during a disaster, test plans before a disaster occurs, and encourage nurses to create a personal emergency preparedness plan for themselves. The nurse manager should not wait until a disaster occurs to create a disaster plan because this can lead to inadequate resources for safe client care.

The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern?

Ignore the racial comments. 2. Discourage the racial comments. (CORRECT) 3. Leave articles about racial prejudice in the nurse's lounge. 4. Report the racial comments to the grievance committee. RATIONALE: Prejudice reduction is a method of managing or discouraging racial comments made by others. When racial comments are discouraged, fewer comments will be made. Ignoring the racial comments is an inappropriate option because the concern will not be addressed. Leaving articles about racial prejudice in the nurse's lounge indirectly addresses the issue. In addition, the nurse cannot ensure that the staff will read the articles. Likewise, reporting the racial comments to the grievance committee does not directly address the issue. The best approach that the nurse could take would be to directly discuss the concern with the staff members. This action is not identified in the options. Therefore, from the options presented, option 4 would most appropriately manage this concern.

A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN makes which suggestion to the community nurse to direct the group most effectively?

Initiate a drug abuse program in all of the schools. 2. Prepare posters that can be distributed to the schools. 3. Seek out the teenage drug abusers and refer them to drug abuse centers. 4. Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem. (CORRECT) Rationale: Option 4 is the only option that addresses the subject of the question and will identify the additional information required by the task force. Options 1, 2, and 3 do not provide the additional information required in order for the task force to proceed with the necessary task of the group.

A new nurse is employed at a local community hospital and is attending an orientation session. The nurse educator conducting the session asks the new nurse to describe an organization's mission statement. The new nurse appropriately responds with which statement?

It describes the benefits available to employees. 2. It outlines what the organization plans to accomplish. (CORRECT) 3. It identifies the policies and procedures of the organization. 4. It defines the rules of the organization that the employees must follow. RATIONALE: All organizations have a purpose or reason for existing. The purpose typically is expressed in the form of a mission statement. The mission statement outlines what the organization plans to accomplish. Sometimes mission statements incorporate statements of philosophy (beliefs), purpose(s), and goals or objectives into a single statement; other times the philosophy, purpose(s), and goals are addressed in addition to the mission statement. These statements serve as a benchmark against which an organization's performance can be evaluated.

A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people other than the team working with the potential recipient is doing the evaluation. Which response should the nurse give to the client?

It helps reduce the cost of the preoperative workup. 2. It saves the client and recipient valuable preoperative time. 3. A sufficient number of people have to review the case so that no information is overlooked. 4. It will avoid a conflict of interest by the team evaluating the recipient and the team evaluating the donor is avoided. (CORRECT) RATIONALE: Both the kidney donor and recipient need thorough medical and psychological evaluation before transplant surgery. To avoid conflict of interest, evaluation of the donor is done by a team different from that caring for the recipient. The psychosocial issues in living-related organ donation may be very complex, and conversations with the donor are held in strict confidence to preserve family relations.

The nurse is aware that criminal offenses would have which characteristics as opposed to civil offenses? Select all that apply.

It is offensive to society in general. (CORRECT) 2. It is detrimental to society as a whole. (CORRECT) 3. It involves an issue against an individual. 4. It involves offenses such as robbery, murder, and assault. (CORRECT) 5. It will result in punishment whose purpose is to deter further crimes. (CORRECT) Rationale: The characteristics of a criminal law involve conduct that is offensive to society in general; is detrimental to society as a whole; involves public offenses such as robbery, murder, and assault; and its purpose is to punish a person for the crime and deter and prevent further crimes. Characteristics of civil law involve conduct that violates a person's rights, is detrimental to that individual, involves an offense that is against an individual, and the law's purpose is to make the aggrieved person whole again and to restore the person to where he or she was.

The nurse is aware that the ethical philosophy of deontology is composed of which "right-making characteristics"? Select all that apply.

Justice (CORRECT) 2. Usefulness 3. Truthfulness (CORRECT) 4. Consequences 5. Fidelity to promises (CORRECT) Rationale: Deontology defines actions as right or wrong based on their "right-making characteristics," which include fidelity to promises, truthfulness, and justice. It specifically does not look at consequences of actions to determine right or wrong. Utilitarianism is a system of ethics that a value is determined by its usefulness.

The nurse was assigned to care for five clients and spent most of the day caring for one of these clients who had just returned from surgery. The nurse did not ask for assistance and did not regularly check on the other clients. During the day, one of the nurse's other clients got out of bed without calling for assistance and fell, breaking his arm. Which possible charges could this nurse face with this situation? Select all that apply.

Libel 2. Battery 3. Negligence (correct) 4. Malpractice (correct) 5. Abandonment of care (correct) Rationale: The nurse could be charged with malpractice, which is failure to meet a legal duty that resulted in harm to another. The nurse could also be charged with negligence, which is the commission of an act or the omission of an act that a reasonably prudent person would have performed in a similar situation, thus causing harm to another person. It is also possible that the nurse could be charged with abandonment of care, which is the wrongful termination of providing client care.

The nurse overhears a client ask the health care provider if the results of a biopsy indicated cancer. The health care provider tells the client that the results have not returned, when in fact, the health care provider is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the health care provider has not shared the results with the client and tells another nurse that the health care provider has lied to the client and that this health care provider probably lies to all of the clients. Which legal tort has the nurse violated by this statement?

Libel 2. Slander(CORRECT) 3. Assault 4. Negligence RATIONALE: Defamation takes place when something untrue is said (slander) or written (libel) about a person resulting in injury to that person's good name and reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Although the health care provider may be aware of the biopsy results, the health care provider decides when it is best to share such a diagnosis with the client.

The nurse calls the health care provider (HCP) of a client scheduled for a cardiac catheterization because the client has numerous questions regarding the procedure and has requested to speak to the HCP. The HCP is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside the client's room and hears the HCP tell the client in a derogatory manner that the nurse "doesn't know anything." The nurse plans to address the HCP's remark, understanding that the HCP has violated which legal tort?

Libel 2. Slander(CORRECT) 3. Assault 4. Negligence RATIONALE: Defamation is a false communication or careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

The nurse posted a comment on a social media site that was unflattering to another nurse. Which accusations can the second nurse bring against the first nurse? Select all that apply.

Libel (CORRECT) 2. Assault 3. Slander 4. Defamation (CORRECT) 5. Malpractice Rationale: The first nurse could be accused of defamation, which is spoken or written statements made maliciously and intentionally that may injure the subject's reputation, and libel, which is malicious or untrue writing about another person that is brought to the attention of others. Assault is an intentional threat to cause bodily harm to another, malpractice is the failure to meet a legal duty that causes harm to another, and slander is malicious untrue spoken words about another person that are brought to the attention of others.

The nurse is caring for an older adult and knows that an ethical dilemma is most likely to occur in this population because of which issues? Select all that apply.

Limited vision (CORRECT) 2. Chronic illness (CORRECT) 3. Increased hearing 4. Improved memory 5. Lack of assertiveness (CORRECT) Rationale: Older adults may be uncomfortable disagreeing with health care providers and see assertive behavior as a demonstration of lack of trust in that provider. Older adults may also have difficulty in communicating ethical issues because of hearing and vision deficits, memory impairments, and chronic illnesses.

An unlicensed assistive personnel (UAP) tells the nurse that she is becoming very frustrated trying to communicate with an older client who is severely hard of hearing and does not have his hearing aid. Which instructions should the nurse recommend to improve communication between the UAP and the client? Select all that apply.

Make sure the environment is well lit. (CORRECT) 2. Face the client and speak slowly and clearly. (CORRECT) 3. Ask the client to repeat what has been said. (CORRECT) 4. Ask mainly questions that can be answered yes or no. 5. Speak loudly and repeat the key phrases over and over. 6. Turn the television volume down while communicating. (CORRECT) Rationale: Words spoken slowly and clearly are more easily understood by the hearing-impaired client. Using other senses promotes communication. Facing the client in optimum light adds sight to the communication process. Asking for feedback verifies that the client has heard what was communicated. Eliminating background noise from the television decreases distraction. Asking questions that can be answered yes or no does not address the client's ability to understand. It only limits communication. Loud speech is often more difficult to be understood and repetition may cause the client to disengage from communication.

The licensed practical nurse knows that which items are examples of common law? Select all that apply.

Malpractice (CORRECT) 2. Informed consent (CORRECT) 3. Nurse practice act 4. American's with Disabilities Act 5. Client's right to refuse treatment (CORRECT) Rationale: Common law results from judicial decisions made in courts when individual legal cases are decided. Malpractice, informed consent, and a client's right to refuse treatment all came from legal decisions. Statutory laws are created by elected legislative bodies. The nurse practice act arises from each state's statutory law and the American's with Disabilities Act arises from Federal statutory law.

The nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is correctly characterized by which statement?

Negligence is strictly prohibited by the nurse practice act. 2. Negligence is strictly prohibited by the institution's own policies. 3. Negligence is defined as a crime that results in the injury of a client. 4. Negligence is defined as the failure to meet established standards of care. (CORRECT) RATIONALE: The legal definition of negligence is the failure to meet accepted standards of care. Option 3 is an incorrect definition of negligence, although injury may have indeed come to the client as a result of negligence. Both the institution and nurse practice acts have provisions that identify and discourage acts of negligence.

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which data would indicate a negative variance?

Normal vital signs in a postoperative craniotomy client 2. Signs of wound healing in a postoperative abdominal incision 3. The presence of dysrhythmias in a client with a myocardial infarction (CORRECT) 4. A client demonstrating accurate insulin administration following teaching RATIONALE: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early so that appropriate action can be taken.

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). After appropriately charting in the medication administration record, which action should the nurse take?

Notify the health care provider immediately of the client's refusal. 2. Make a notation regarding the client's refusal in the nurse's notes. (CORRECT) 3. Make a note for the nurse on the evening shift to give the medication. 4. No further action is required because it is a client's right to refuse medication. RATIONALE: If a client misses or refuses a dose of medication, the nurse should record in the nurse's notes the reason that the medication was not given. It is unnecessary to notify the health care provider immediately because of the nature of the medication and the client's reason for refusal. The licensed practical nurse should, however, inform the registered nurse. Option 3 is incorrect because medications are not left for the nurse on the next shift to administer because of client refusal. Option 4 is incorrect. An explanation of the missed dose should be recorded.

The nurse has just been licensed and has begun to practice in an acute health care facility. The nurse knows that which nursing specialties will require more specific defined standards of care and skills? Select all that apply.

Nurse-midwives (CORRECT) 2. Nurse-anesthetists (CORRECT) 3. Intensive care unit (ICU) nurses (CORRECT) 4. Postsurgical care unit nurses 5. Respiratory disease unit nurses Rationale: Nurses are responsible for meeting the same standards as other nurses practicing in similar settings. Specialized nurses such as nurse anesthetists, ICU nurses, and certified nurse-midwives have specially defined standards of care and skills. Nurses who care for clients on medical surgical units do not usually require these specially defined standards of care and skills.

The nurse has just finished taking a course on disaster preparedness. Which statements by the nurse indicate that the teaching has been effective? Select all that apply.

Nurses test plans by participating in disaster drills." (CORRECT) 2. "Nurses are not a key part of disaster preparedness." 3. "Nurses play key roles before, during, and after a disaster." (CORRECT) 4. "Nurses do not evaluate the effectiveness of the plans after disaster drills." 5. "Nurses assist in developing internal and external emergency response plans." (CORRECT)

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which action in the care of this client?

Obtain a court order for the surgery. 2. Send the client to surgery without the consent form being signed. 3. Have the hospital chaplain sign the informed consent immediately. 4. Obtain telephone consent from the family member witnessed by two persons. (CORRECT) Rationale: Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In emergencies, the client may be unable to sign, and family members may not be available. In this type of situation, the health care provider is permitted legally to perform surgery without consent. Options 1 and 3 are not appropriate. In addition, actions that delay treatment in an emergency are not appropriate.

An adult client is brought to the emergency department by the emergency medical services team after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. With regard to informed consent for the surgical procedure, which nursing action is correct?

Obtain a court order for the surgical procedure. 2. Transport the victim to the operating room for surgery. (CORRECT) 3. Call the police to identify the client and locate the family. 4. Ask the emergency medical services team to sign the informed consent. Rationale: Generally in only two instances is the informed consent of an adult client not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Option 1 is unnecessary, and option 4 is inappropriate. Although option 3 may be pursued, it is not the best initial action.

A vascular surgeon repeatedly asks the nurse to obtain signed consent forms on his surgical clients. The nurse is uncomfortable with obtaining the informed consents and explains this to the surgeon, but the surgeon tells the nurse that she will be reported if the consents are not obtained. The nurse should appropriately manage this situation by taking which action?

Obtain the informed consents. 2. Discuss the situation with the nurse manager. (CORRECT) 3. Contact the national medical association and report the surgeon. 4. Tell the surgeon, "I don't really care if you report me. I am not obtaining the consents." RATIONALE: If a conflict arises, it is most appropriate to try to resolve the conflict directly. In this situation, the nurse has attempted to explain the reasons for being uncomfortable with the surgeon but was unable to resolve the conflict. The nurse would then appropriately use the organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the surgeon or seek assistance from the nursing supervisor. Options 1, 3, and 4 are inappropriate actions. Option 1 ignores the issue. Option 3 is inappropriate because the nurse needs to use the appropriate organizational channels of communication to resolve the conflict. Option 4 is an inappropriate statement and will initiate further conflict between the nurse and surgeon.

The nurse is planning the client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Obtaining frequent oral temperatures on a client 2. Collecting a urine specimen from a client admitted 3 days ago 3. Assisting a child who is profoundly developmentally disabled to eat lunch (CORRECT) 4. Accompanying a client being discharged to home following a bowel resection 8 days ago to their transportation RATIONALE: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for the nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore has a higher potential for complications, such as choking and aspiration. The remaining options do not include data indicating that these tasks carry any unforeseen risk.

Which is a recommended guideline for safe computerized charting?

Passwords to the computer system should only be changed if lost. 2. Computer terminals may be left unattended during client-care activities. 3. Accidental deletions from the computerized file need to be reported to the nursing manager or supervisor. (correct) 4. Copies of printouts from computerized files should be kept on a clipboard at the nurses' station for other nurses to access. rationale: After any inadvertent deletions of permanent computerized records, the nurse should type an explanation into the computer file with the date, time, and his or her initials. The nurse should also contact the nursing manager or supervisor with a written explanation of the situation. Options 1, 2, and 4 represent unsafe charting actions. Only option 3 follows the guidelines for safe computer charting.

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action should be implemented?

Performing the surgery without an informed consent 2. Having the client sign the consent form because this is an emergency situation 3. Calling the family and telling them that they must come to the hospital immediately to sign the informed consent 4. Obtaining a telephone consent from the family member and ensuring that the oral consent is witnessed by two persons (CORRECT) RATIONALE: Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent and document the name of the family member, noting that an oral consent was obtained. In emergencies, the client may be unable to sign and family members may not be available. In this type of a situation, the health care provider is legally permitted to perform surgery without consent. Consent is not informed if it is obtained from the client who is confused, unconscious, mentally incompetent, or under the influence of sedatives.

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next?

Place dry, sterile dressings over the eyes of the deceased. 2. Call the National Donor Association to confirm that the client is a donor. 3. Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes. (CORRECT) 4. Ask the wife to obtain the legal documents regarding organ donation from the lawyer. RATIONALE: When a corneal donor dies, antibiotic eyedrops may be prescribed and instilled. The eyes are closed and a small ice pack is placed on the closed eyes. The head of the bed is raised to 30 degrees to prevent edema. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Option 1 is incorrect because dry dressings are not applied. Some organ donation protocols indicate using normal saline-moistened gauze. Option 2 is not an immediate action. In addition, the client should have a signed donor card, living will, or an organ donor-identified driver's license stating his or her wishes. Additional legal documentation should not be required. Agency procedures regarding donor care should be followed.

The licensed practical nurse (LPN) enters a client's room and finds the client sitting on the floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and health care provider (HCP) are notified of the incident. Which is the next nursing action regarding the incident?

Place the incident report in the client's chart. 2. Make a copy of the incident report for the HCP. 3. Document a complete entry in the client's record concerning the incident. (correct) 4. Document in the client's record that an incident report has been completed RATIONALE: The incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any reference made to it in the client's record. The incident report is not a substitute for a complete entry in the client's record concerning the incident.

The licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that which is the initial step in the process of change?

Plan strategies to implement the change. 2. Set goals and priorities regarding the change process. 3. Identify the inefficiency that needs improvement or correction. (CORRECT) 4. Identify potential solutions and strategies for the change process. Rationale: When beginning the change process, the nurse should identify and define the problem or the inefficiency that needs improvement or correction. This important first step can prevent many future problems because if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, identifying potential solutions and strategies, and setting goals and priorities. The nurse then plans strategies to implement the change.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action?

Prepare the triage rooms. 2. Activate the agency emergency response plan. (CORRECT) 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist with treating the casualties. RATIONALE: During a widespread disaster, many people will be brought to the emergency department for treatment. Although options 1, 3, and 4 may be components of preparing for the casualties, the initial nursing action should be to activate the emergency response plan.

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Providing time for unexpected tasks 2. Prioritizing client needs and daily tasks 3. Gathering supplies before beginning a task 4. Documenting task completion at the end of the day (CORRECT) RATIONALE: The nurse should document task completion continually throughout the day. Options 1, 2, and 3 identify accurate components of time management.

The nurse is present at a disaster scene and is participating in the triage of victims. Which color tag should be assigned to a victim with evidence of open pneumothorax?

Red (CORRECT) 2. Black 3. Green 4. Yellow Rationale: An open pneumothorax can be a life-threatening situation unless immediately managed. The victim has a reasonable chance of survival if immediate treatment is instituted, so a red tag should be attached to the victim. Yellow tags are placed on victims whose injuries can wait for treatment without threat to life, for example, closed fractures. Green tags are placed on victims with minimal injury, for example, minor lacerations or those experiencing anxiety related to the disaster. Black tags are reserved for those who are dead or whose injuries are so extensive there is no chance of survival.

The nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is angry with the assignment because of a belief that the assignment is more difficult than the assignment delegated to other nurses on the unit. The nurse should carry out which action?

Refuse to do the assignment. 2. Tell the nurse manager to call the nursing supervisor. 3. Ask the nurse manager of the neurological unit to discuss the assignment. (CORRECT) 4. Return to the cardiac unit and discuss the assignment with the nurse manager on that unit. RATIONALE: If the nurse feels that the assignment is more difficult than the assignment delegated to other nurses on the unit, the nurse should discuss the assignment with the nurse manager of the neurological unit. The nurse may or may not have a more difficult assignment than the other nursing staff. However, this action will assist in either identifying the rationale for the assignment or determining if the assignment is actually more difficult. The nurse should not refuse an assignment. Specific situations may be present in which the nurse should not take care of a specific client. An example of this type of situation may be if a pregnant nurse is assigned to care for a client with rubella or a client with an internal radiation implant. In these situations, the nurse also should discuss the assignment with the nurse manager. The nurse should not return to the cardiac unit. This action indicates client abandonment. In addition, this action does not address the conflict directly. Option 1 is an aggressive action and does not address the conflict directly.

A pediatric nurse arrives at work and is told to report (float) to the emergency department (ED) for the day because the ED is expecting numerous victims to arrive following a train crash. The nurse has never worked in the ED and is anxious about floating to this area. Which is the appropriate nursing action?

Refuse to float to the ED. 2. Ask another pediatric nurse to float to the ED. 3. Tell the nursing supervisor that she is feeling sick and needs to go home. 4. Discuss her anxieties and concerns with the nursing supervisor about floating. (CORRECT) RATIONALE: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, the nurse should discuss any anxieties and concerns with the nursing supervisor about floating. Options 1 and 3 may be interpreted as client abandonment. Although option 2 may be an alternative option at some point, it is not the appropriate action.

After reviewing the psychosocial implications following a disaster, the nurse is assigned to care for a client who has just witnessed a mass shooting. Upon obtaining subjective information from the client, which actions should the nurse take? Select all that apply.

Remain calm and reassuring. (CORRECT) 2. Allow the client to remain alone. 3. Convey caring behaviors towards the client. (CORRECT) 4. Establish rapport and actively listen to the client. (CORRECT) 5. Avoid discussing the disaster so that the client will not be upset. Rationale: One of the most important roles of the nurse after a community disaster is health assessment, including psychosocial health. It is important that the nurse remain calm and reassuring and convey caring behaviors. The nurse should establish a rapport with the client and actively listen to what the client is saying. Allowing the client to remain alone without support or avoiding discussion of the disaster could be destructive to the psychosocial health of the client.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor. (CORRECT) RATIONALE: Nurse practice acts require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing. Options 1 and 2 are inappropriate. Option 3 may cause a conflict.

The nurse suspects that a co-worker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action should the nurse take?

Report the information to the police. 2. Report the information to a supervisor. (CORRECT) 3. Confront the co-worker about the suspicion. 4. Call the impaired nurse organization and report the co-worker. RATIONALE: An impaired nurse is one who is unable to function effectively because of some type of substance abuse. Nurse practice acts require reporting the suspicion of impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor who will then report to the board of nursing. Options 1, 3, and 4 are incorrect. Confronting the nurse may cause a conflict. The supervisor will report the substance abuse situation as necessary.

A licensed practical nurse (LPN) is collecting data on a child and notes the presence of old and new bruises on the child's back and legs. The LPN suspects physical abuse and reports the findings to the registered nurse knowing that which action is necessary?

Reporting the case to legal authorities (CORRECT) 2. Filing charges against the mother and father of the child 3. Asking the mother to identify the person who is physically abusing the child 4. Telling the child that he or she will need to go to a foster home until the situation is straightened out Rationale: The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. It is not appropriate for the nurse to file charges against the father or mother. It is also inappropriate to ask the mother to identify the abuser because the abuser may be the mother. If so, the mother may become defensive and attempt to leave the emergency department with the child. Option 4 is clearly inappropriate and will produce fear in the child

The nurse observes that an older male client is confined to his room by his daughter-in-law. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way, and my son needs me to stay here." Which is the best nursing intervention for this situation?

Say to the son, "Confining your father to his room is inhumane." 2. Say nothing; it is best for the nurse to remain neutral and to wait to be asked for help. 3. Suggest to the client and daughter-in-law that they consider a nursing home for the client. 4. Suggest appropriate resources such as respite care and a senior citizens' center to the client and daughter-in-law. (CORRECT) RATIONALE: Assisting clients and families with becoming aware of available community support systems is a role and responsibility of the nurse. Suggesting to the client and daughter-in-law to place the client in a nursing home is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of nursing care required. Observing that the client is confined to his room makes it necessary for the nurse to intervene legally and ethically, so saying nothing in order to remain neutral is not appropriate and is passive in terms of advocacy. Telling the son that confining his father to his room is inhumane is incorrect and judgmental.

A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which statement made by the student indicates a need for further study of the levels of prevention?

Screening for hypertension in a community 2. Teaching a stroke client how to use a walker (CORRECT) 3. Encouraging a client to take antihypertensive medications as prescribed 4. Encouraging a woman older than age 40 to obtain periodic mammograms Rationale: Secondary prevention focuses on the early diagnosis and prompt treatment of disease. Tertiary prevention is represented by rehabilitation services. Options 1, 3, and 4 identify screening procedures and treatment of disease, whereas option 2 identifies a rehabilitative service.

After weeks of witnessing a man's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which criterion does the nurse use to determine if the autopsy can proceed?

Specifics in the client's will 2. Decision by the client's sister 3. Ruling from medical examiner 4. Determination by the client's son (CORRECT) RATIONALE: The nurse works with the client's son to determine if an autopsy can be performed (option 4) because the only powers that supersede an offspring's decision are the client's written statement, a durable power of attorney, or a surviving spouse. In order, a parent, brother, or sister can make the decision if the client has no children. A client's will involves bequeathing property and does not contain information about medical care (option 1). The client's sibling is consulted after an offspring (option 2). The client's death is unlikely to be a medical examiner's case or a suspicious death, so a medical examiner's ruling is not indicated.

A client has just been treated with cardioversion. The nurse should check which measure first?

Status of airway (CORRECT) 2. Blood pressure 3. Oxygen flow rate 4. Level of consciousness RATIONALE: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority

A client with chronic obstructive pulmonary disease (COPD) asks the nurse for assistance with preparing a living will. The client tells the nurse that she has not discussed the living will with the family and wanted to make some decisions before discussing the will with the family. Which initial step in preparing this document should the nurse inform the client to do?

Talk to the family. 2. Contact a lawyer. 3. Consult with the American Lung Association. 4. Discuss the request with the health care provider. (CORRECT) RATIONALE: The client should discuss the request for a living will with the health care provider. The client should also discuss this desire with the family, although in this situation, based on the client's feelings, talking to the family would be the second step. Wills should be prepared with legal counsel and should identify the executor of the estate, address distribution and use of property, and specific plans for burial. Although option 1 may be helpful, this contact would not be the initial step. The lawyer would be contacted following discussion with the health care provider and family.

The nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which is the appropriate nursing action?

Tell the client that the family must agree with the request. 2. Plan a client conference with the nursing staff to share the client's request. 3. Tell the client that it is necessary to notify the health care provider of the client's request. (CORRECT) 4. Tell the client that this procedure cannot legally be refused by a client if the health care provider feels that it is necessary to save the client's life. Rationale: External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the health care provider because a written "do not resuscitate" (DNR) order from the health care provider must be present on the client's record. The DNR order must be reviewed or renewed on a regular basis per agency policy. Options 1 and 4 are inaccurate. Option 2 may be appropriate, but only after the health care provider is contacted and notified of the client's request.

The nurse is caring for a pediatric client who sustained physical injuries following a bombing. Which actions by the nurse should help put the child at ease and decrease the child's and family's stress level? Select all that apply.

Tell the truth about the child's status. (CORRECT) 2. Communicate an attitude of confidence. (CORRECT) 3. Encourage family caregivers to stay with the child. (CORRECT) 4. Limit communicating the child's status with the family. 5. Establish a trusting relationship with the child and the parents. (CORRECT) Rationale: After a disaster, it is important to tell the truth about the child's status to the parents and the child; this will establish trust. An attitude of confidence helps ease stress levels. The family caregivers should be encouraged to stay with the child to eliminate additional anxiety, such as separation anxiety. Establishing a trusting relationship is needed during times of stress. Communication should not be limited because that can increase the levels of stress.

The unlicensed assistive personnel (UAP) who has been employed in a long-term care facility for 8 weeks is consistently 10 to 20 minutes late for work. The UAPs lateness has caused unrest with other staff members in the nursing unit. The UAP is due to receive a 3-month probation evaluation in 1 month. Which is the most appropriate action by the nurse in charge of the nursing unit when dealing with this situation?

Telling the other staff members to cover for the UAP until she arrives 2. Telling the UAP that she will be fired if the behavior does not change 3. Addressing the lateness with the UAP at the 3-month probation evaluation 4. Confronting the UAP to discuss the lateness and initiate problem-solving measures (CORRECT) RATIONALE: Arriving late to work is an unacceptable behavior. Although the UAPs behavior has caused unrest with other staff members, the primary concern is that this behavior affects client care. The nurse in charge needs to confront the UAP and discuss the lateness and initiate problem-solving measures that ensure that the behavior does not continue. It is not appropriate to wait 1 month to address the behavior (option 3). It is also inappropriate to expect other staff members to cover for the UAP until she arrives. In addition, this action will increase the unrest with the staff members. Telling the UAP that she will be fired if the behavior does not change does not provide confrontation or address problem solving. However, firing may be an outcome if adequate warning has been issued and a change in behavior does not occur.

The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?

Temperature 2. Urine output 3. Blood pressure 4. Respiratory status (CORRECT) RATIONALE: Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be a component of the data collection process, option 4 identifies the priority nursing action.

The nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for what evidence that supports this information?

Testimony of three neighbors 2. A judicial decision in a court of law (CORRECT) 3. A health care provider's prescription 4. A licensed nurse's observation of bizarre behavior RATIONALE: Appointment of a guardian must be done through due legal process. It cannot be done by a health care provider's prescription. Options 1 and 4 could support the decision that a legal guardian is necessary if the client is incompetent to make his or her own decisions, but they are not sufficient by themselves.

The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used.

The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea 1 The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute 2 The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 3 The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching 4 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching Rationale: The nurse should prioritize visits to clients based on the client's risks for physiological changes. The nurse should first see the client with HF who had to increase the elevation of the head of the bed in order to sleep. The client with a heart rate of 70 beats per minute who is receiving digoxin (Lanoxin) should be seen next because this is a circulation issue; the client's heart rate should be between 80 and 100 beats per minute. The next client to be seen is the client with rheumatic fever and a pain level of 8/10. Lastly, the client scheduled for surgery should be seen for preoperative teaching.

The nurse witnesses an accident in which the victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to a victim who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files suit against the nurse who provided care at the scene of the accident. Which accurately describes the nurse's immunity from this suit?

The Good Samaritan laws will not protect the nurse. 2. The Good Samaritan laws will protect the nurse if the care given at the scene was not negligent. (CORRECT) 3. The Good Samaritan laws protect laypersons and not professional health care providers. 4. The Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided. RATIONALE: A Good Samaritan law is passed by a state legislator to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called "immunity from suit," this protection usually applies only if all of the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent.

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?

The RN will be charged with assault. 2. The RN will be charged with slander. 3. The RN will be charged with imprisonment. 4. No charge will be made against the RN because the RN's actions are reasonable. (CORRECT) RATIONALE: False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client was voluntarily admitted and if there are no agency or legal policies for detaining the client. On the other hand, if the client has been involuntarily admitted or has agreed to an evaluation before discharge, the nurse's actions are reasonable.

The nurse is observing a an unlicensed assistive personnel (UAP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed?

The UAP consistently speaks directly to the client. 2. The UAP touches the client's arm to gain the client's attention. 3. The UAP consistently faces the client when speaking to the client. 4. The UAP stresses words by overenunciating them when speaking. (CORRECT) RATIONALE: Overenunciating words does not make lip reading easier and is demeaning to the deaf person. It is best to speak in a normal manner. Options 1, 2, and 3 are appropriate communication strategies for the client who is deaf.

A resident in a long-term care facility refuses a medication that has been prescribed. The nurse takes appropriate action after considering which fact?

The client cannot be forced to take the medication. (correct) 2. The client has now become legally incompetent. 3. The client can be forced to take the medication if the health care provider prescribed it. 4. The client will probably take the medication if the health care provider personally administers each dose. RATIONALE: Option 1 is a true statement. The client has the right to refuse any medication prescribed unless deemed incompetent in a court of law. Options 2 and 3 are incorrect statements. Option 4 is an opinion not supported by fact.

A client receives meperidine (Demerol) by the intramuscular route. Thirty minutes after receiving the medication, the client develops signs of an allergy to the medication. The client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client and contacts the registered nurse, who then contacts the health care provider. The nurse completes an incident report and accurately documents which?

The client experienced an allergy to the meperidine. 2. The health care provider was notified because the client developed a rash after receiving meperidine. 3. The client apparently is allergic to meperidine as noted by a temperature of 101° F, warm and flushed skin, and a rash on the chest and back. 4. Thirty minutes after receiving meperidine, the temperature is 101° F, skin is warm and flushed, and a rash is noted on the chest and back; the health care provider was notified. (CORRECT) RATIONALE: The nurse should document relevant information in an accurate, complete, and objective form. Option 1 does not identify objective data. Option 3 makes an interpretation about the occurrence. Although option 2 identifies accurate information, it is incomplete.

A client who had a lung resection for cancer has been told that bone metastasis has occurred. The client is considering megavitamin and diet therapy because the original surgery did not provide a cure. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates which concepts?

The client's right to justice and the nurse's obligation to project this right 2. The client's right to privacy and the nurse's obligation to uphold the law 3. The client's right to autonomy and the nurse's obligation to behave ethically (CORRECT) 4. The client's right to freedom of speech and the nurse's obligation to support the client RATIONALE: The client has the right to autonomy, or the exercise of personal choice. At the same time, the nurse has the obligation to behave ethically. Some unconventional cancer treatments have not been proven to be effective, may be toxic to the client, and may be extremely expensive. The nurse balances the client's right to self-determination with the obligation to share with the client knowledge about the ineffectiveness of these methods. Privacy is the right of a client to be free from intrusion by someone into their own personal affairs. Justice is the ethical principle of treating people fairly.

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider that the client had terminal cancer. The emergency department health care provider examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate?

The decision is made by the medical examiner." 2. "An autopsy is mandatory for any client who is DOA." 3. "I will contact the medical examiner regarding your request." (CORRECT) 4. "It is required by federal law. Why don't we talk about it, and why don't you tell me how you feel?" Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. The client may have provided oral or written instructions regarding an autopsy following death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

After pleading for information, a visitor learns from the nurse that his friend (the client) has died from human immunodeficiency virus (HIV). Inadvertently, the visitor informs the client's family about the client's HIV diagnosis. Which is the most serious potential consequence of possible damages caused by these events?

The family confronts the friend with hostility. 2. The agency issues internal disciplinary action. 3. The state convicts the nurse for invasion of privacy. (CORRECT) 4. The nursing board fines the nurse for ethical violation. RATIONALE: Nursing ethics include the nurse's promise to perform care with nonmaleficence and to maintain client privacy. The nurse's duty was to avoid releasing information about a client to others; however, the nurse released personal client information to a third party. This is an action that is a violation of nursing ethics, clients' rights, and civil law. As a result, the nurse could face civil action for invasion of privacy if the family can prove damages. The family can confront the friend about the veracity of the statement, the agency can issue an internal reprimand against the nurse, and the state board can issue an ethical reprimand; however, option 3 is the most serious consequence of the nurse's action because it most likely involves an award for the family.

The nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to an unlicensed assistive personnel (UAP). The UAP notifies the nurse that the client's vital signs are elevated and the client is complaining of pain and dyspnea. Which is appropriate regarding the nurse's next action?

The nurse asks another UAP to confirm the client's vital signs. 2. The nurse requests that the UAP take the client's vital signs again. 3. The nurse calls the health care provider and reports the client's current physical condition. 4. The nurse checks the client and gathers additional data before calling the health care provider. (CORRECT) RATIONALE: The nurse must not depend on the judgment of a UAP because the nurse is responsible for supervising those to whom client care has been delegated. Therefore, options that have UAPs recheck vitals are incorrect. A call to the health care provider may be warranted, but the nurse has insufficient data at this time, making this option incorrect. In order to provide the client with the degree of care required, the nurse must gather additional information and analyze that information before notifying the health care provider, making this the correct choice.

The nurse is aware that which criteria are necessary for a situation to be classified as malpractice? Select all that apply.

The nurse disliked the client. 2. The client sustained an injury. (CORRECT) 3. The nurse owed a duty to the client. (CORRECT) 4. The nurse did not carry out a duty to a client. (CORRECT) 5. The client's injury was caused by the nurse's failure to duty. (CORRECT) Rationale: When nursing care falls below a standard of care, nursing malpractice results. Certain criteria are necessary to establish nursing malpractice: (1) the nurse owed a duty to the client, (2) the nurse did not carry out that duty, (3) the client was injured, and (4) the nurse's failure to carry out the duty caused the injury. It does not matter if the nurse liked or disliked the client.

A client had a colon resection. A Salem tube was in place when a regular diet was brought into the client's room. The client did not want to eat solid food and asked that the health care provider be called. The nurse persisted in the belief that the solid food was the correct diet. The client ate two meals and subsequently had additional surgery due to complications. The nurse understands that the determination of negligence in this situation is based on what?

The nurse's beliefs 2. A duty existed and it was breached (correct) 3. Not calling the health care provider 4. The dietary department sending the wrong food RATIONALE: Proven negligence requires a duty, a breach of duty, the breach of duty must cause the injury, and damages or injury must be experienced. Options 1, 3, and 4 do not fall under the criteria for negligence. Option 2 is the only option that fits the criteria of negligence.

A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths?

They are developed based on appropriate standards of care." 2. "They are nursing care plans and use the steps of the nursing process." (CORRECT) 3. "They are developed through the collaborative efforts of all members of the health care team." 4. "They provide an effective way to monitor care and for reducing or controlling the length of hospital stay for the client." Rationale: Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. Options 1, 3, and 4 appropriately describe the use of a critical path

A nurse lawyer provides an education session to the nursing staff regarding client rights. The nurse asks the lawyer to describe an example that may relate to invasion of client privacy. Which nursing action indicates a violation of client privacy?

Threatening to place a client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs of the client without consent (CORRECT) 4. Telling the client that he or she cannot leave the hospital RATIONALE: Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment

The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process?

To make sure the pharmacy knows what medications the client was taking at home 2. To make sure the client is well informed about why each medication needs to be taken 3. To make sure medical insurance companies have a complete list of the client's medications 4. To compare a client's medication prescriptions to all of the medications the client is taking at home (CORRECT) RATIONALE: Medication reconciliation is a process of comparing a client's medication prescriptions to all of the medications the client is taking. It helps avoid medication errors related to omissions, duplications, dosing errors, and drug interactions and is done at every transition of care when new medications are prescribed or rewritten. This process does not directly affect the pharmacy or insurance company. It is not related to teaching clients about their medications, although nurses still must inform clients about what medications they are taking and why they need to take them.

A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of his leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client?

Use of padded restraints to immobilize the limb (correct) 2. Performing range of motion to the affected limbs 3. Removing potentially harmful objects near the spastic limbs 4. Use of as-needed (PRN) prescriptions for muscle relaxants such as baclofen (Lioresal) RATIONALE: Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. Removing potentially harmful objects is an important safety measure. Use of muscle relaxants also is indicated if the spasms cause discomfort to the client or pose a risk to the client's safety. Use of limb restraints will not alleviate spasticity and could harm the client.

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel?

Witnessing the client sign the procedure consent form 2. Determining if the client has understood the instructions given 3. Answering the call light promptly after the enema has been given (CORRECT) 4. Ensuring the client has consumed a soft diet the evening before the exam RATIONALE: Clients frequently have strong urges to defecate after receiving enemas and laxatives to prepare for the colonoscopy. It is not appropriate to provide a soft diet the evening before the exam; clear liquids only are provided. It is also inappropriate to delegate to the nursing assistant the responsibility to determine if the client understood instructions or to sign the procedure consent form. The unlicensed assistive personnel is trained to answer call lights.

a nurse manager is providing information about the audit process to members of the nursing team. which of the following information should the nurse manager include?

a. a structure audit evaluates the setting and resources available to provide care (correct): a structure audit evaluates the setting in which care is provided and includes resources such as equipment and staffing levels b. an outcome audit evaluates the results of the nursing care provided (correct): an outcome audit evaluates the effectiveness of nursing care. it should include the observable data, such as infection rates among client c. a root cause analysis is indicated when a sentinel event occurs (correct): a root cause analysis is indicated when a sentinel even occurs. a sentinel even is a serious problem such as injury to or death of a client. immediate investigation of the problem is indicated. the health care team can use root cause analysis to study the problem and take measures to prevent reoccurrence. d. retrospective audits are conducted while the client is receiving care e. after data collection is completed, it is compared to a benchmark (correct): the benchmark is set at the beginning of the process and then it is compared to the data after collection is completed

a nurse is hired to replace a staff member who has resigned. after working on the unit for several weeks, the nurse noticed that the unit manager does not intervene when there is conflict between team members, even when it escalates. which of the following conflict resolution strategies is the unit manager demonstration?

a. avoidance (correct) b. smoothing c. cooperating d. negotiating RATIONALE: the goal in resolving conflict is a win-win situation. the unit manager is using an ineffective strategy, avoidance, to deal with the conflict. she is aware of the conflict but is not attempting to resolve it.

a nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. which of the actions should the nurse take first?

a. call the provider b. ask a staff member for assistance getting the client back in bed c. inspect the client for injuries (correct) d. instruct the client to ask for help if he needs to get out of bed RATIONALE: the first action the nurse should take using the nursing process is to assess the client

a PN ending her shift reports to the RN that a newly hired AP has not calculated the I&O for several clients. which of the following actions should the RN take?

a. complete an incident report b. delegate this task to the pn c. ask the AP if she needs assistance (correct) d. notify the nurse manager rationale: the nurse should find out what the AP knows about performing the task and provide education for the AP if indicated

a nurse manager is working with a committee of nurses to update policies for new employee orientation. the nurse manager directs the team to collect as much data as possible and recommend several options. which of the following decision-making styles is the nurse manager demonstrating?

a. decisive b. flexible c. hierarchical d. integrative (correct) rationale: when the integrative decision-making style is used, the team uses a large amount of data and generates several options

a nurse is participating in a quality improvement study of a procedure frequently preformed on the unit. which of the following information will provide data regarding the efficacy?

a. frequency with which procedure is performed? b. client satisfaction with performance of the procedure c. incidence of complications related to procedures (correct) d. accurate documentation of how procedure was performed rationale: the incidence of complications related to the procedure is an outcome measure directly related to the efficacy of the procedure.

a nurse on a telemetry unit is caring for a client who was admitted 2 hours ago and has chest pain. the client becomes angry and tells the nurse that there is nothing wrong with him and that he is going home immediately. which of the following actions should the nurse take?

a. notify the client's family of his intent to leave the facility b. document that the client left the facility against AMA (correct): when documenting a discharge, the nurse should document the type of discharge, including an AMA discharge. c. explain to the client the risks involved if the chooses to leave (correct): the nurse is legally responsible to warn the client of the risks involved in leaving the hospital AMA d. ask the client to sign a form relinquishing responsibility of the facility (correct) clients who leave the hospital prior to discharge are asked to sign a form to provide legal protection for the hospital e. prevent the client from leaving the facility until the provider arrives

an RN on a med-surg unit is making assignments at the beginning of the shift. which of the following tasks should the nurse delegate to the PN?

a. obtain vital signs for a client who is 2 hrs post op following a cardiac catheterization (correct) b. administer a unit of packed rbcs to a client who has cancer c. instruct a client who is scheduled for discharge in the performance of wound care d. develop a plan of care for a newly admitted client who has pneumonia rationale: it is within the scope of practice of the PN to monitor a client who is 2hr post-op for a cardiac catheterization

a nurse is participating in an inter professional conference for a a client who has a recent C6 spinal cord injury. the client worked as a construction worker prior to his injury. which of the following members of the inter-professional team should participate in planning care for the client?

a. physical therapist (correct): the client will need the assistance of a [physical therapist to assist with mobility skills and maintain muscle strength b. speech therapist c. occupational therapist (correct): the client will need the assistance of an occupational therapist to learn how to perform activities of daily living d. psychologist (correct): the client will need the assistance of a psychologist to adapt to the psychosocial impact of the injury e. vocational counselor (correct): the client will need the assistance of a vocational counselor to explore options for re-employment

a nurse manager is developing an orientation plan for newly licensed nurses. which of the following information should the manager include in the plan?

a. skill proficiency (correct) :the purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. the nurse manager should include evaluation of skill proficiency and provide additional instruction as needed. b. assignment to a preceptor (correct): the purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. the nurse manager should include assignment of a preceptor to ease the transition of the newly licensed nurse c. budgetary principles d. computerized charting (correct): the purpose of orientation is to assist the new nurse from the role of student to the role of employee and licensed nurse. the nurse manager should include computerized charting, which is a vital skill for the newly licensed nurse. e. socialization into unit crime (correct): the purpose of orientation is to assist the new nurse to transition from the role of student to the role of nurse/employee. the nurse manager should include socialization to the unit as a way to ease the transition of the newly licensed nurse. f. facility policies and procedures (correct): the purpose of orientation is to assist the newly licensed nurse. the nurse manager should include information about facility policies and procedures, which is essential information for the newly licensed nurse.

a nurse is preparing to transfer an older adult who is 72 hr post-op to a long-term care facility. which of the following info should the nurse include in the transfer report?

a. type of anesthesia used b. advanced directive status (correct): the receiving nurse and facility need to know advance directive status in order to provide care and address the client's current needs c. vital signs on the day of admission d. medical dx (correct): the receiving nurse and facility need to know the client's medical dx in order to provide care and address the client's current needs e. need for specific equipment (correct): the receiving nurse and facility need to know the client's need for specific equipment in order to provide care and address the client's current needs.

a nurse who has just assumed the role of unit manager is examining her skills in inter professional collaboration. which of the following actions support the nurse's inter professional collaboration?

a. use aggressive communication when addressing the team b. recognize the knowledge and skills of each member of the team (correct): the nurse should recognize that each member of the team haas specific skills to contribute to the collaboration process c. ensure that a nurse is assigned to serve was the group facilitator for all interprofessional meetings (correct): the nurse is legally responsible to warn the client of the d. encourage the client and family to participate in the team meeting (correction): collaboration should occur among the client, family, and interprofessional team e. support team member requests for referral (correct) the nurse should support suggestions for referrals to link clients to appropriate resources

The nurse is aware that the American's with Disabilities Act provides which rights to individuals who are disabled? Select all that apply.

abels asymptomatic HIV as a disability (CORRECT) 2. Protects the privacy of individuals with HIV (CORRECT) 3. Provides employment to persons with disabilities 4. Prohibits discrimination in employment and public services (CORRECT) 5. Allows health care workers to refuse to care for a client with HIV

A client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses the client 15 minutes after administering the medication and reminds the client to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Which issues support the client's malpractice claim? Select all that apply.

ailure to replace body fluids 2. Increased risk of hypotension (CORRECT) 3. Failure to teach the client adequately (CORRECT) 4. Increased need to protect the client (CORRECT) 5. Excessive bumetanide administration 6. Lack of follow-up nursing actions (CORRECT) Rationale: To prove malpractice against the nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3, 4, and 6) after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

A licensed practical nurse has decided to purchase disciplinary defense insurance and is aware that this type of insurance would provide which type of benefits? Select all that apply.

epresentation by a qualified attorney (correct) 2. Payment to an individual for negligent care 3. Reimbursement for travel to the state board of nursing (correct) 4. Payment of all legal fees for defense of negligent care 5. Payment of all legal fees for defense of a nursing license (correct) Rationale: Disciplinary defense insurance provides benefits if the individual has had action brought against a nursing license by a state board of nursing. The benefits of this insurance are to provide a qualified nurse attorney or attorney to represent the nurse and to pay for or reimburse the nurse for this attorney. It will reimburse for loss of wages and also for travel, food, and lodging to a hearing at the state board of nursing. It does not pay legal fees or any monetary benefit to an individual if the nurse is involved in a lawsuit related to negligent care.

The nurse shares with a client that violation of a civil law usually results in which type of penalty? Select all that apply.

onetary fine (CORRECT) 2. Public service (CORRECT) 3. Replacement of property (CORRECT) 4. Imprisonment for more than 1 year 5. Monetary fine and imprisonment for less than 1 year Rationale: Civil laws protect the rights of individuals within our society, and the consequences of civil law violations are damages in the forms of fines or specific performance of good works such as public service. A monetary fine, public service, and replacement of damaged property would be examples of this. Criminal law protects society as a whole and provides punishment of crimes. A felony (serious crime) is punishable by imprisonment for more than 1 year. A misdemeanor (less serious crime) is punishable by payment of a fine and imprisonment for less than 1 year.

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept?

"It is managing client care by managing the client care environment." 2. "It represents a primary health prevention focus managed by a single case manager." (CORRECT) 3. "It maximizes hospital revenues while providing for optimal outcome of client care." 4. "It is designed to promote appropriate use of hospital personnel and material resources." RATIONALE: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. Options 1, 3, and 4 identify the components of managed care.

The new nurse graduate asks another nurse about the need to obtain professional liability insurance. Which is the most appropriate response by the nurse?

"The hospital insurance covers your actions." 2. "Nurses need to have their own malpractice insurance." (CORRECT) 3. "It is very expensive and you really don't need it because the hospital covers you." 4. "The lawsuits are filed against health care providers and the hospital, so you are safe not to obtain it." RATIONALE: Nurses need their own liability insurance for protection against malpractice lawsuits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse's actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements?

"They are specific guidelines." (CORRECT) 2. "They define professional practice." 3. "They have some similarity to policies and procedures." 4. "They are authoritative statements that describe a common or acceptable level of client care or performance." RATIONALES: Standards of care are authoritative statements that describe a common or acceptable level of client care or performance that have some similarity to policies and procedures. Thus, standards of care define professional practice. The American Nurses Association has formulated general standards and guidelines for nursing practice. They are broad and general in nature and apply across the nation.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed (correct) RATIONALE: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks. When faced with this situation, the nurse should identify potential areas of harm to the client

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

1. Autocratic (correct) 2. Situational 3. Democratic 4. Laissez-faire RATIONALE: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to the work group.

The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first?

A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count (CORRECT) 2. A client admitted with pneumonia 4 days ago, who will be discharged later this morning 3. A client with a head injury sustained 3 days ago who is alert but complaining of a headache 4. A client with diabetic ketoacidosis, admitted 2 days ago, whose blood glucose is 180 mg/dL RATIONALE: A client with right lower quadrant abdominal pain should be assessed first because these symptoms are commonly associated with acute appendicitis. A client who is to be discharged does not need to be checked first. A headache is common with head injuries, but the client is alert, indicating stability. A blood glucose of 180 mg/dL is of concern, but the client's blood glucose was likely much higher on admission and thus is more stable at this time.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing RATIONALE: The airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 would have intermediate priority

Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?

A client who is loud, talkative, and pacing back and forth, interrupting others 2. A client who is crying, saying that her family has abandoned her at the facility 3. A client who says that voices sponsored by the FBI are telling him to stab his roommates (CORRECT) 4. A client who is constantly looking over her shoulder, saying, "They're always out to get me." RATIONALE: A client who hears voices telling him to harm others should be treated first. This client has a very high risk of self-harm and harming others. The clients in options 1, 2, and 4 do not exhibit symptoms that present a risk of harming others.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will. (CORRECT) 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency. RATIONALE: Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility in which the client is receiving care.

A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action?

Discuss the client's request with the family. 2. Document the client's request in the client's record. 3. Notify the health care provider of the client's request. (correct) 4. Conduct a client conference to share the client's request RATIONALE: External cardiac massage is one type of treatment that a client can refuse. The appropriate initial action is to notify the health care provider (HCP) because a written "do not resuscitate" (DNR) prescription from the HCP must be present. The DNR prescription must be reviewed or renewed on a regular basis, per agency policy.

The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility?

Report the case in which the abuse is suspected. (correct) 2. Refer the family to the appropriate support groups. 3. Assist the family in identifying resources and support systems. 4. Document the child's physical assessment findings accurately and thoroughly. RATIONALE: The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the case.

The health care provider writes a prescription for the nurse to obtain a consent for a colonoscopy. Which are the nurse's responsibilities to obtain an informed consent? Select all that apply.

To ensure the client knows all the risks 2. To ensure the client is the age of consent (CORRECT) 3. To ensure the client is signing voluntarily (CORRECT) 4. To allow family members to sign if the client is disoriented 5. To obtain a court order if the family objects to the procedure RATIONALE: Witnesses are required to meet the state's legal requirements. A witness only verifies that this is the person who signed the consent and that it was a voluntary consent. The witness (often the nurse) does not verify that the client understands the procedure; this is the surgeon's responsibility. Informed consent should not be obtained if the client is disoriented; a family member legally can only sign a consent under certain situations, such as in an emergency. If family members object to surgery that the surgeon believes is essential, a court order may be obtained for the procedure. This practice is used only in extreme circumstances.

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

roviding clients with necessary stabilizing treatments 2. A method of promoting quality care and risk management (correct) 3. Determining the effectiveness of interventions in relation to outcomes 4. The appropriate method of reporting to local, state, and federal agencies RATIONALE: Proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency. Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present. Options 1, 3, and 4 are incorrect.