Nurs 2101 remaining chapters

The patient lives in an apartment and has difficulty getting on and off of the toilet. Which is the best intervention to protect the patient's safety? a. Place a bedside commode over the toilet. b. Screw grab bars into the wall by the toilet. c. Attach suction cup grab bars to the wall by the toilet. d. Instruct the patient to lean forward when rising to stand.

ANS: A A bedside commode should be placed over the patient's toilet to make it safer for the patient. Grab bars should not be screwed into the wall as the patient is renting the apartment. Suction cup grab bars may not attach securely to the wall. The patient should not be instructed to lean forward when rising to stand.

The nurse is caring for a patient who has ongoing headaches, nausea, dizziness, and fatigue since the weather turned cold and snowy. Which assessment question is most important to ask the patient? a. "Has your furnace been inspected lately?" b. "Have you checked your roof for any leaks?" c. "When was the last time your house was painted?" d. "When did you change your smoke detector batteries?"

ANS: A A furnace, stove, or fireplace that is not properly vented introduces carbon monoxide into the environment. This gas binds strongly with hemoglobin, preventing the formation of oxyhemoglobin and thus reducing the supply of oxygen delivered to the tissues. Low concentrations cause nausea, dizziness, headache, and fatigue. The importance of having a proper working smoke detector will decrease the chance of smoke inhalation and potential death owing to a fire but does not produce the symptoms listed. A leaking roof and lead paint would not cause the patient's symptoms.

Which assessment finding indicates that the patient is at higher risk for a motor vehicle accident? a. The patient is 18 years of age b. The patient drives a bright blue sedan. c. The patient is the youngest of six children. d. The patient has a history of juvenile arthritis.

ANS: A According to the CDC, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. Therefore the patient's age of 18 years indicates a higher risk of a motor vehicle accident. Driving a bright blue sedan, being the youngest child and a history of arthritis do not put the patient at higher risk of motor vehicle accident.

Which ethical principle is violated when the patient is not told the truth about the medical diagnosis and therefore is not able to decide on the course of treatment? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

ANS: A Autonomy refers to a person's independence. As a principle in bioethics, autonomy represents an agreement to respect a patient's right to determine a course of action. Justice refers to the principle of fairness: fair treatment and fair distribution of health care resources. Fidelity refers to the agreement to keep promises and is based on the virtue of caring. Nonmaleficence is actively seeking to do no harm.

The nurse respects the patient's wish not to be intubated even though the patient will most likely die as a result of the decision. Which ethical theory is demonstrated by the action of the nurse? a. Autonomy b. Justice c. Utilitarianism d. Responsibility

ANS: A Autonomy refers to the patient's right to make decisions and determine a course of action. This is upheld when the nurse respects the patient's wish not to be intubated. Justice refers to the principle of treating all patients fairly. Utilitarianism determines the value of something based primarily on its usefulness and benefit for the greater good. Responsibility refers to reliability and dependability in the performance of duties.

The nurse cuts an unconscious patient's long hair in order to wash and brush it. The patient wakes up and is very upset after seeing the short hair. Which tort did the nurse commit? a. Battery b. Assault c. Slander d. Negligence

ANS: A Battery is intentional offensive touching without consent or lawful justification. Assault is an intentional threat toward another person that gives that person a reasonable fear of harmful contact. No actual contact is required for an assault to occur. Negligence is an unintentional tort. Slander is making malicious statements that can damage an individual's reputation.

Which assessment finding indicates that the patient is at risk for developing hypothermia? a. The patient is disoriented due to senile dementia. b. The patient is 5-foot 6-inch tall with a BMI of 35. c. The patient has a history of congestive heart failure. d. The patient takes three different antihypertensive medications.

ANS: A Elderly confused patients are at risk for hypothermia due to wandering and unawareness of surroundings. The patient's BMI of 35 indicates obesity which would not put the patient at risk for hypothermia. Antihypertensive medications and a history of CHF do not increase risk of hypothermia.

The nurse is providing discharge instructions to the patient. Which grade level should the instructions be written at as the nurse does not know the patient's educational background? a. Fifth-grade b. Seventh-grade c. Ninth-grade d. Eleventh-grade

ANS: A Individualize teaching materials to meet the patient's needs and match the patient's reading level; if a nurse does not know the patient's reading level, information should be provided at a fifth-grade or lower level. Sixth-, eighth-, and ninth-grade levels are too high.

Which patient scenario allows the physician to perform needed procedures without the need to obtain informed consent first? a. An unconscious patient is brought into the ER after an auto accident. b. The patient speaks only Russian and requires the services of a translator. c. The patient is deaf and communicates through sign language or lip reading. d. The patient is not an American citizen and does not have any health insurance.

ANS: A Informed consent may not be obtained from an unconscious trauma patient. Informed consent must be obtained with a translator for patients who do not speak English. Deaf patients require sign language translators. Lack of health insurance does not eliminate the need for informed consent.

Which intrinsic assessment finding could lead a patient to fall? a. The patient has orthostatic hypotension and faints when standing too quickly. b. The patient's room is located at the end of the hall far from the nursing station. c. The patient's roommate sometimes spills the contents of a urinal on the floor. d. The patient's room is crowed with walkers, wheelchairs, and bedside commodes.

ANS: A Intrinsic factors that can lead to falls are patient-related such as orthostatic hypotension. Extrinsic factors are environmentally related, such as spills, clutter, and patient room location.

The patient suffers a large hematoma at the site after arterial blood gases (ABGs) are drawn by the respiratory therapist. Which statement is appropriate to enter in the patient's chart? a. Patient has a painful, raised 2-inch 2-inch hematoma inside his right wrist after ABGs were drawn there. b. The patient must have moved during the ABG draw because there is a huge bruise inside his wrist. c. The respiratory therapist had a hard time getting the patient's ABGs drawn and caused bruising. d. The respiratory therapist obviously didn't know what he was doing and traumatized the patient's wrist.

ANS: A Narrative notes must be objective without opinions, speculation, or blame. The nurse should chart the location and size of the hematoma along with the reason. The nurse should not speculate that patient moved or that the respiratory therapist did not know how to perform the skill.

In which case might the patient be ordered by the court to receive treatment? a. The patient has infectious TB and refuses to take the prescribed antibiotics. b. The patient's mother refuses a vaccine for her child because he is allergic to it. c. A Jehovah's Witness refuses a blood transfusion based on religious convictions. d. A patient refuses treatment to slow the advancement of an inoperable brain tumor.

ANS: A Patients whose refusal of treatment may endanger the health of the public may be ordered by the court to receive treatment. An example of this is a patient who has infectious TB and refuses to take prescribed antibiotics. The court will not require Jehovah's Witness patients to receive blood transfusions or require surgery for inoperable tumors. Allergy to a vaccine is a valid reason for refusal.

Which patient is appropriate for the nursing diagnosis readiness for enhanced knowledge related to the prescribed treatment regimen? a. The patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. b. The patient who insists that the blood sugar levels will never stabilize no matter how many medications are taken. c. The patient who believes that influenza was contracted as a result of the flu immunization last year. d. The patient who was just diagnosed with diabetes and has no idea about how to inject insulin.

ANS: A Readiness for enhanced knowledge related to the prescribed treatment regimen indicates that the patient is already knowledgeable and wishes to learn more. Readiness for enhanced knowledge is appropriate for the patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. Readiness for enhanced knowledge is not appropriate for patients who do not want to learn or who have not obtained a basic understanding of the concepts already.

Which nursing diagnosis is the highest priority for a sexually active adolescent? a. Risk for infection related to participation in unprotected sexual activity b. Disturbed body image related to depersonalization and fear of rejection c. Spiritual distress related to inability to integrate sexuality with church teaching

ANS: A Risk for infection related to participation in unprotected sexual activity is the highest priority nursing diagnosis as the patient's physical health is in danger. Disturbed body image, spiritual distress, and risk for compromised human dignity may be addressed once the patient has demonstrated understanding of safe sex practices

Which nursing diagnosis is the highest priority for a family with small children? a. Risk for suffocation related to unattended swimming pool in back yard b. Risk for caregiver role strain related to four children under 6 years of age c. Readiness for enhanced immunization status related to request for medical records d. Readiness for enhanced parenting related to attachment between family members

ANS: A Risk for suffocation related to unattended swimming pool in back yard is the highest priority nursing diagnosis because drowning could lead to permanent injury or death. Risk for caregiver role strain, readiness for enhanced immunization status, and readiness for enhanced parenting are lower priority diagnoses as they address psychosocial needs. They can be attended to after the immediate risk for danger is addressed.

The nurse is providing discharge instructions to a patient with memory loss after a head injury. What is the most appropriate action of the nurse? a. Teach the patient and a responsible family member at the same time. b. Teach the patient using simple terminology and a louder tone of voice. c. Teach the patient the most important information first followed by lesser facts. d. Teach the patient immediately before discharge so the patient will remember it.

ANS: A The discharge information should be provided to the patient's responsible family member as well as the patient since the patient may not remember it. Speaking loudly will not help the patient to remember the information. Giving the most important information first immediately before discharge will not help the patient to remember the information.

A patient's spouse smokes cigarettes in the kitchen while the patient uses supplemental oxygen in the bedroom. Which is the priority nursing diagnosis for this family? a. Risk for injury related to smoking near supplemental oxygen b. Risk-prone health behavior related to inability to quit smoking c. Ineffective health maintenance related to continued use of cigarettes d. Ineffective family therapeutic regimen management related to noncompliance

ANS: A The highest priority nursing diagnosis is risk for injury (burns, fire) related to smoking near supplemental oxygen. A life-threatening fire could easily develop as the supplemental oxygen is near the spouse's cigarettes. Risk-prone health behavior, ineffective health maintenance, and ineffective family therapeutic regimen management are not the priority nursing diagnoses; these can be addressed after the safety risk has been mitigated.

The nurse is frustrated with an agitated patient and tells him "Now stay in that bed or I will make you stay there!" Which tort has the nurse just committed? a. Assault b. Battery c. Incursion d. Onslaught

ANS: A The nurse has committed assault by threatening the patient. No actual contact is required for an assault to occur. Battery occurs when the patient is touched without consent. Onslaught and incursion are not legal terms.

Which ethical area is challenged when the nurse feels bound to refuse to assist with an abortion procedure? a. Values b. Culture c. Confidentiality d. Social networking

ANS: A The nurse is having a conflict in values because of religious beliefs and abortion. A value is a personal belief about the worth of an idea, a custom, or an object. Confidentiality is not the issue because no confidences have been broken. Social networking is online communication, which is not the issue in this scenario, values are the issue. The nurse is not having a conflict in culture, but in beliefs and values.

Which is the appropriate action for the nurse manager when a nurse refuses to assist with an abortion due to personal ethical beliefs? a. Assign the nurse to care for other patients. b. Counsel the nurse about professional responsibility. c. Report the nurse's refusal to the State Board of Nursing. d. Inform the nurse that the refusal will lead to termination.

ANS: A The nurse manager should assign the nurse to care for other patients so that the nurse does not have to go against personal ethical beliefs. Counseling the nurse about professional responsibility will not resolve the current staffing issue and the nurse will not change ethical beliefs about abortion. Reporting the nurse to the State Board of Nursing and threatening termination are not appropriate as nurses are allowed to refuse assignments such as abortions based on their personal ethical beliefs.

The nurse is caring for a patient who will have surgery. The nurse witnesses the patient sign the informed consent document, and then the nurse adds her signature as a witness. What does the nurse's signature on the document mean? a. The patient signed the form, not someone else. b. The patient accepts the potential risks of the procedure. c. The patient fully understands the procedure to be performed. d. The patient agrees with the surgeon's planned treatment approach.

ANS: A The nurse's signature on the consent form indicates only that the patient signed the form, not someone else. The nurse's signature on the consent form does not indicate that the patient accepts the potential risks of the procedure, fully understands the procedure to be performed or agrees with the surgeon's planned treatment approach.

A patient smokes in the hospital bathroom and starts a fire. Which is the nurse's first response? a. Remove the patient to a safe area. b. Close the door to contain the fire. c. Call the operator to activate the fire alarm. d. Utilize a fire extinguisher to put out the fire.

ANS: A Use the mnemonic RACE to set priorities in case of fire: R—Rescue and remove all patients in immediate danger. A—Activate the alarm. Always do this before trying to extinguish even a minor fire. C—Confine a fire by closing doors and windows and turning off oxygen and electrical equipment. E—Extinguish a fire using an appropriate extinguisher. Reporting, attempting to extinguish, and closing the door all occur after assisting patients to a safe area.

The nurse has received an order to administer warfarin 100 mg PO today to the patient. This amount seems high to the nurse. Which are the appropriate actions of the nurse? (Select all that apply.) a. Clarify the order with the physician. b. Document suspicion about the order. c. Notify the nursing supervisor on duty. d. Administer the medication as ordered. e. Question the pharmacist about the dosage.

ANS: A, C, E Nurses are responsible for carrying out medical treatment unless the physician's or health care provider's order is in error, violates hospital policy, or is harmful to the patient. Therefore it is imperative to assess all orders and, if they appear to be erroneous or harmful to the patient, to O M obtain further clarification from the physician or health care provider. 100 mg is not an appropriate dosage of warfarin so it should not be administered to the patient. Do not carry out the order if there is a risk that harm will come to your patient; therefore do not administer the medication. The nursing supervisor should be notified. The pharmacist should be contacted about the order. Inform the nurse manager or the nursing supervisor. The nurse does not document suspicions or opinions, just objective, factual information.

Which statement made by the patient indicates readiness for learning about colostomy care? a. "I don't want to look at it and I can't imagine caring for it." b. "The sooner I can take care of it, the sooner I can go home." c. "I never thought I would have to take care of something like this." d. "I hope I can still wear a bathing suit with this thing."

ANS: B "The sooner I can take care of it, the sooner I can go home" indicates that the patient is ready to learn about how to take care of the colostomy. The patient realizes that discharge from the hospital depends on the ability to care for the colostomy so the patient is amenable to teaching about how to care for it. "I don't want to look at it and I can't imagine caring for it" indicates that the patient does not wish to learn about colostomy care. "I never thought I would have to take care of something like this" is an emotional statement that indicates a need for support from the nurse. "I hope I can still wear a bathing suit with this thing" addresses a need for reassurance about appearance and activity after colostomy surgery.

The nurse is accused of stealing narcotic pain medications from patients. Which type of crime may the nurse be charged with? a. Tort b. Felony c. Malpractice d. Misdemeanor

ANS: B A felony is a serious offense that results in significant harm to another person or society in general. Felony crimes may carry penalties of monetary restitution, imprisonment for greater than 1 year, or death. Examples of Nurse Practice Act violations that may carry criminal penalties include practicing nursing without a license and misuse of controlled substances. A misdemeanor is a crime that, although injurious, does not inflict serious harm. Torts are civil wrongful acts or omissions against a person or a person's property that are compensated by awarding monetary damages to the individual whose rights were violated. Malpractice is an example of negligence, sometimes referred to as professional negligence.

The nurse attempts to teach the patient about wound care in a loud semiprivate room with many distractions. Which is the appropriate action of the nurse? a. Explain to the patient that all of the information about wound care is in the handout provided. b. Take the patient to a quiet private treatment room to teach the patient about how to perform wound care. c. Ask the distraught roommate to please be considerate of the patient while the nurse is teaching about wound care. d. Arrange for the home-health nurse to provide teaching about wound care after discharge from the hospital.

ANS: B A quiet area is needed for learning. Before learning anything, patients must be able to pay attention to or concentrate on the information they will learn. Physical discomfort, anxiety, and environmental distractions make it more difficult for a patient to concentrate. It is not appropriate to refer the patient to a handout. Asking the roommate to be considerate is inappropriate because the roommate is distraught. Deferring patient teaching to the home-health nurse is not appropriate.

The nurse administers the wrong dose of medication and then blames the mistake on a co-worker. Which ethical principle is violated by the nurse? a. Fidelity b. Accountability c. Confidentiality d. Social networking

ANS: B Accountability refers to the nurse's ability to take responsibility for actions or decisions. The nurse in this situation failed to be accountable for the medication error by blaming it on a co-worker. Confidentiality is the protection of patient information so that it is not shared with others. Fidelity is an agreement to keep a promise. Social networking refers to the use of social media to connect with patients, family members, and friends.

The nurse is applying soft wrist restraints to the patient. Where will the restraints be tied to the patient's bed? a. Side rails b. Bedframe c. Footboard d. Headboard

ANS: B Attach restraint straps to the portion of the bedframe that moves when raising or lowering the head of the bed. Do not attach to the side rails. Attaching the restraint straps to a portion of the bedframe that does not move (headboard or footboard) will injure the patient

Which ethical area is involved when the clinic releases genetic test results to the patient's employer without the patient's consent? a. Veracity b. Bioethics c. Justice d. Beneficence

ANS: B Bioethics is a division of ethics that deals with appropriate use of medical technology. Bioethics includes decisions regarding organ transplants, genetic testing, and quality of life. Beneficence refers to helping others. Justice refers to the principle of fairness: fair treatment and fair distribution of health care resources. Veracity is telling the truth.

Which chart entry documents patient achievement of cognitive learning? a. The patient verbalized decreased desire to commit self-harm. b. The patient described three symptoms of diabetic ketoacidosis. c. The patient demonstrated how to perform active range of motion. d. The patient expressed satisfaction with ability to share feelings with others.

ANS: B Cognitive learning includes what the patient knows and understands. All intellectual behaviors are in the cognitive domain. Describing symptoms of DKA is an example of cognitive learning. Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Examples of psychomotor learning include how to perform active range of motion. Affective learning includes the patient's feelings, attitudes, opinions, and values such as decreased desires and satisfaction.

Which type of reinforcement is used when the nurse gives a sticker to a pediatric patient every time the incentive spirometer is used? a. Social b. Material c. Activity d. Negative

ANS: B Examples of material reinforcers are food, toys, and music. These work best with young children. Use social reinforcers (e.g., smiles, compliments, words of encouragement, or physical contact) to acknowledge a learned behavior. Activity reinforcers (e.g., physical therapy) rely on the principle that a person is motivated to engage in an activity if there is an opportunity to participate in more desirable activity upon completion of this first activity. Negative reinforcement (frowning) may work but people usually respond better to positive reinforcement.

The home care nurse suspects that the patient's bedsores are due to neglect from family caregivers. Which is the appropriate action of the nurse? a. Inform the caregivers that their actions are illegal. b. Report it to the proper legal authority immediately. c. Call the agency's security department to handle the problem. d. Prevent the caregivers from being responsible for the patient's care.

ANS: B Health care providers are required to report incidents such as child, spousal, or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable diseases. Health care providers are provided legal immunity if the report is made in good faith. Not reporting suspected abuse or neglect can cause a nurse to be liable in civil or criminal legal actions. It is not the nurse's responsibility to inform the caregivers of illegal activity or to prevent the caregivers from seeing the patient. The nurse is responsible for reporting the suspected abuse, not call security to handle the problem.

Which is the highest priority concern for the nurse who is educating the homeless patient about medications, appointments, and therapies for management of diabetes? a. Motivation b. Health literacy c. Developmental stage d. Psychomotor learning

ANS: B Health literacy includes patients' reading and math skills, comprehension, the ability to make health-related decisions, and successful functioning as a consumer of health care. It is a strong predictor of health status and patient outcomes. The homeless patient is at high risk for having minimal health literacy. Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Developmental stage is not as important as health literacy and developmental stage is more important when teaching children. Motivation is an internal impulse, such as an emotion or need, which prompts, guides, and sustains human behavior.

The nurse is caring for a patient who had a stroke because of lack of understanding about how to take the prescribed blood pressure medication. Which is the priority nursing diagnosis for this patient? a. Noncompliance related to patient's refusal to follow the prescribed treatment regimen b. Ineffective therapeutic regimen management related to lack of understanding about prescribed medications c. Ineffective health maintenance related to lack of expressed interest in taking prescribed medications correctly d. Readiness for enhanced decision making related to desire to choose the course of action that best meets health needs

ANS: B Ineffective therapeutic regimen management related to lack of understanding about prescribed medications is the priority nursing diagnosis for the patient because the patient's knowledge deficit about the prescribed medications led to the stroke. The nurse will help teach the patient about the medications and ensure that they are taken exactly as prescribed. Nothing indicates that the patient refused to follow the prescribed treatment plan or that the patient was not interested in taking the prescribed medications. Readiness for enhanced decision making is not the priority diagnosis as it does not address the patient's need to take prescribed medications correctly.

Which ethical principle is upheld when uninsured patients receive the same level of care as patients with private health insurance? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

ANS: B Justice refers to the principle of fairness. In health care, the term is used to reflect a commitment to fair treatment and fair distribution of health care resources. You may find reference to this principle during discussion about issues of access to care. It is not always clear just how to achieve a fair distribution of resources. Autonomy refers to independence and self-determination. Fidelity refers to the agreement to keep promises and is based on the virtue of caring. Nonmaleficence refers to the fundamental agreement to do no harm.

Which teaching approach is demonstrated when the nurse provides guidance while the patient performs the sterile dressing change? a. Telling b. Entrusting c. Reinforcing d. Participating

ANS: B The entrusting approach provides the patient the opportunity to manage self-care. The patient accepts responsibilities and correctly performs the task while a nurse observes the patient's progress and remains available for assistance. Telling involves explicit instructions with no feedback. Participating involves mutual goal setting with the patient helping decide the content. Reinforcing is using a stimulus that increases the probability of a response.

The nurse is caring for a patient who has a do-not-resuscitate order from the physician in the chart. The patient stops breathing and his skin turns blue. What is the best action of the nurse to avoid a lawsuit for malpractice or wrongful death? a. Call the Rapid Response Team in case the patient's wife changes her mind. b. Stay with the patient and offer support to the family members in the room. c. Verify that the do-not-resuscitate order is signed by the physician and valid. d. Review the nursing policy and procedure manual for resuscitation guidelines.

ANS: B The nurse should follow the do-not-resuscitate order and allow the patient to die without lifesaving intervention. The nurse should stay with the patient and offer support to the family members in the room. The Rapid Response Team should not be called. The nurse should validate the do-not-resuscitate order before the patient stops breathing. The nurse should review the nursing policy and procedure manual for resuscitation guidelines before starting the shift.

The patient's family members disagree about which treatment is most appropriate for the terminally ill comatose patient. Which nursing intervention is most appropriate for this situation? a. The nurse will provide statistical information about the patient's odds of survival. b. The nurse will promote effective communication between the family members. c. The nurse will ask the family members to leave medical decisions to the physician. d. The nurse will wait until the patient is able to make the decisions about treatment.

ANS: B The nurse should promote effective communication between the family members so that they can come to an agreement about the patient's treatment. Providing statistical information about survival odds is not helpful for moral decision making in this case. The family members should not leave the medical decision to the physician as the treatment may not be consistent with their beliefs. The patient will not be able to make decisions about treatment.

Which patient care need may be delegated to the nursing assistant? a. Providing discharge teaching about fall precautions in the home b. Responding to the patient's bed alarm as the patient attempts to get up c. Performing a mental status assessment to check for confusion or delirium d. Obtaining a consult for physical therapy for strengthening/balance exercises

ANS: B The nursing assistant can respond to the patient's bed alarm as the patient attempts to get up. The registered nurse should provide teaching, perform assessments, and obtain consults for the patient.

Which assessment finding leads the nurse to add ineffective protection to the patient's care plan? a. The patient follows a gluten-free, low-sodium, antiinflammatory diet. b. The patient has not received immunizations against influenza or pneumonia. c. The patient recently divorced after being in an unhappy marriage for 4 years. d. The patient takes levothyroxine daily to treat hypothyroid disease.

ANS: B The patient is susceptible to influenza and pneumonia due to lack of immunization against these diseases. Ineffective protection is an appropriate nursing diagnosis for the patient as there is a decreased ability to protect itself from infection. Levothyroxine, divorce, and dietary preferences do not lower the patient's defenses.

Which nursing diagnosis indicates that the patient will have difficulty learning how to perform sterile dressing changes at home? a. Deficient knowledge related to diabetic wound management b. Stress overload related to ongoing emotional abuse and bullying c. Readiness for enhanced knowledge related to diabetes management d. Impaired physical mobility related to need to use a cane for ambulation

ANS: B The patient who is overly stressed will have difficulty learning procedures or concepts. The nurse should expect to spend extra time helping the patient to learn. Impaired physical mobility will not impair learning ability. The patient's deficient knowledge about wound management justifies the need for teaching. Readiness for enhanced knowledge indicates that the patient is ready to learn.

Which situation gives the patient cause to sue for malpractice due to injury or harm? a. The patient developed an itchy rash after receiving a prescribed antibiotic. b. The patient died after being struck in the head by an oxygen tank during an MRI. c. The patient developed a sore throat after being intubated for emergency surgery. d. The patient developed permanent joint deformity due to severe rheumatoid arthritis.

ANS: B To establish the elements of malpractice, the patient or plaintiff must prove the following: (1) the nurse defendant owed a duty to the patient, (2) the nurse breached that duty, (3) the patient was injured because of the nurse's breach of duty, and (4) the patient has accrued damages as a result of the injury. Patient death due to injury from an oxygen tank in the MRI room is an example of malpractice as the professionals should have taken the proper precautions. Itchy rash after antibiotic use is a side effect. Sore throat after intubation is an expected complication. Permanent joint deformity due to severe rheumatoid arthritis is an unfortunate outcome of chronic illness.

When a parent asks how to seat a 6-year-old child in the family car, how will the nurse respond? a. In the rear seat with lap and shoulder seat belts b. In the front seat with lap and shoulder seat belts c. In the rear seat with a belt-positioning booster seat d. In the front seat with a belt-positioning booster seat

ANS: C All children under age 13 should ride in the rear seat. Children less than 8 years of age should be in a belt-positioning booster seat as they are not tall enough to fit into the lap and shoulder seat belts.

Which assessment finding best indicates to the nurse that the teaching about a dressing change was successful? a. The patient understands how to change the dressing using sterile technique. b. The patient verbalizes understanding about how to change the sterile dressing. c. The patient correctly demonstrates the dressing change using sterile technique. d. The patient acknowledges the principles of sterile technique for dressing changes

ANS: C Demonstration is the best method to evaluate a psychomotor skill. Examples of evaluating the effectiveness of teaching include having patients show how to perform a newly learned skill (e.g., self-catheterization) or asking patients to explain how they will incorporate newly ordered medications into their daily routines. Evaluating the effectiveness of teaching for a psychomotor skill includes a demonstration, not understanding or acknowledging. Just stating, "Yes" does not indicate learning like a demonstration does

A patient with a rare neurological disease is misdiagnosed by the physician and told that the symptoms are psychosomatic. The patient's sense of self is shattered after being told "You are a waste of a hospital bed." Which ethical theory is violated in this situation? a. Liberty b. Fidelity c. Ethics of care d. Confidentiality

ANS: C Ethics of care suggest that health care workers resolve ethical dilemmas by paying attention to relationships and stories of the participants and by promoting a fundamental act of caring. Attention to relationships distinguishes the ethics of care from other ethical viewpoints because it does not necessarily apply universal principles that are intellectual or analytical. The physician in this situation did not demonstrate any care or compassion for the patient and violated the ethics of care. Liberty is the freedom to choose without intimidation or oppression from others. Confidentiality was not breached as the physician did not share patient information with others or fail to provide privacy. Fidelity is an agreement to keep a promise.

The patient undergoes surgery for a herniated disk and is paralyzed afterward. What must the patient prove to the court in order to win a malpractice lawsuit based on lack of informed consent? a. The patient's paralysis was not due to the surgeon's technique. b. The patient's signature on the consent form was witnessed by his nurse. c. The surgeon performed a laminectomy but the patient consented to a fusion. d. The surgeon performed a surgical procedure that was known to be high risk.

ANS: C If the patient consented to a fusion but the surgeon performed a laminectomy, the patient may win a malpractice suite based on lack of informed consent. The surgeon must perform the procedure indicated on the patient's consent form. The risk of the surgical procedure does not correlate with lack of informed consent. The patient's signature on the consent form may be witnessed by the surgeon or the nurse. The patient cannot win a malpractice lawsuit based on lack of informed consent because the paralysis was not caused by the surgeon.

The nurse filled out an incident report after a patient fall but makes no mention of the incident report in her notes in the patient's chart. What is the reason for this? a. The incident report includes the nurse's interpretations of what probably led the patient to get out of bed. b. A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. c. The incident report is confidential and not intended to be used as evidence in a malpractice suit. d. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report.

ANS: C Incident reports are used by facilities to investigate the event and prevent possible recurrence. The nurse does not include presumptions or speculations about the incident in the patient chart or the incident report. The incident report is submitted to the unit manager, administration, and/or agency attorney for review. The incident report is never filed in the patient's chart. The presence of an incident report will not increase risk of a malpractice lawsuit.

Which is the role of the nurse regarding a malfunctioning IV pump? a. Contact the IV pump manufacturer. b. Initiate a work order on the IV pump. c. Tag the IV pump and remove it from the area. d. Clean the fixed IV pump and return it to the floor

ANS: C Initiating the work order on the pump is important, but the first priority is to tag and remove the pump from service. Leaving the pump in the equipment closet could allow the pump to mistakenly be put back into service without be fixed. It is not within the nurse's role to call the pump manufacturer to report the issues. Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid accidents, do not operate medical equipment without adequate instruction. If you discover a faulty piece of equipment, replace it with the proper working equipment, place a tag on the faulty one, take it out of service, and promptly report any malfunctions.

Which description of the state Nurse Practice Act is correct? a. It is a judicial decision. b. It is a federal senate bill. c. It is a statute enacted by state legislature. d. It is a law enacted by the federal government.

ANS: C Nurse Practice Acts are examples of statutes enacted by state legislatures to regulate the practice of nursing. Common laws are based on judicial decisions or case law precedent. An example of a judicial decision that guides health care practice is Roe v. Wade, but not the Nurse Practice Act. An example of a federal statute that affects health care practice is the Americans With Disabilities Act, but not the Nurse Practice Act. The Nurse Practice Act is a state law, not a federal senate bill.

Which situation will enable a nurse to use restraints? a. To punish a patient b. To ensure staff convenience c. To ensure the patient's safety d. To retaliate against poor behavior

ANS: C Regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patient's safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation.

The nurse often forgets to administer the patient's medication exactly on time, frequently giving it 1 or 2 hours after it is due. Which ethical principle is violated by the nurse? a. Justice b. Judgment c. Responsibility d. Confidentiality

ANS: C Responsibility refers to trustworthiness and constancy in the performance of duties. The nurse is violating the principle of responsibility by failing to consistently administer the patient's pain medication on time. Justice refers to the principle of treating all patients fairly. Confidentiality is the protection of patient information so that it is not shared with others. Judgment is the ability to make sound decisions based on the available information.

The nurse educator uses manikins to teach patients how to correctly perform CPR on a victim of cardiac arrest. Which teaching technique is used by the nurse? a. Analogy b. Role play c. Simulation d. Enunciation

ANS: C Simulation is a useful technique for teaching problem solving, application, and independent thinking. During individual or group discussion, the nurse presents a problem or situation pertaining to the patients' learning for patients to solve. In this case, the manikins are used to simulate a victim of cardiac arrest. During role play, your patients play themselves or someone else in the situation. Analogies add to verbal instruction by providing familiar images that make complex information more real and understandable. Enunciation is pronouncing words clearly.

Which information must be obtained from the patient upon admission to the hospital? a. Patient's religious preference b. Health insurance authorization c. Presence of an advanced directive

ANS: C The Patient Self-Determination Act (1991) requires health care institutions to inquire whether a patient has created an advance directive, give patients information on advance directives, and document whether a patient states that he or she has an advance directive. Asking how payment will be made is not required by law and is not the responsibility of the nurse

The patient is aggressively attempting to pull out IV lines and hurt staff members. Which is the first action of the nurse? a. Conduct a thorough mental status assessment. b. Contact the health care provider to obtain an order for restraints. c. Place the patient in soft restraints to prevent injury. d. Document the patient's actions in the medical record.

ANS: C The first priority of the nurse is to restrain the patient to prevent injury to the patient or others. The health care provider can then be contacted to obtain an order for restraints. The patient's actions can later be documented in the medical record. A thorough mental status assessment can be performed once the patient has been restrained and there is no risk of injury.

A nurse wants to follow nursing standards of care. Which document should the nurse follow? a. National League for Nursing manuscript b. World Health Organization guiding principles c. Health care agency's written procedure manual d. US Department of Health and Human Services guidelines

ANS: C The health care agency's written procedure manual is defined as a standard of care. Standards of care are defined by the following: (1) state Nurse Practice Acts, (2) state and federal hospital licensing laws and accreditation rules, (3) professional and specialty organizations, and (4) written policies and procedures of the nurse's health care agency. Manuscripts are not standards of care. The World Health Organization and US Department of Health and Human Services are not state or federal hospitals or professional and specialty organizations for nurses.

The patient's home is filled with papers S and trash that has accumulated over the last 20 years. Which is the priority nursing diagnosis for the patient? a. Unilateral neglect related to inadequate support systems b. Ineffective coping related to hoarding behaviors c. Risk for falls related to cluttered walkways and untidy environment d. Readiness for enhanced comfort related to desire for nicer surroundings

ANS: C The highest priority nursing diagnosis is risk for falls related to cluttered walkways and untidy environment. Fall risk is more important than ineffective coping or readiness for enhanced comfort. Unilateral neglect is the lack of awareness of a body part following a stroke.

While at the grocery store, the nurse witnesses another shopper collapse near the checkout. The nurse performs CPR and the patient survives after being treated at the hospital. The patient later attempts to sue the nurse for malpractice because several ribs were broken as a result of chest compressions. Why will the patient's lawsuit be thrown out of court? a. The patient should not have been at the grocery store with a history of heart disease. b. The patient needed to disclose her history of heart disease to the nurse before she collapsed. c. The patient's rib fractures occurred as a result of properly performed CPR by the nurse. d. The nurse's personal liability insurance company decided to settle rather than face a jury.

ANS: C The nurse is covered by the Good Samaritan law as long as the care provided meets expected standards. The patient's rib fractures occurred as a result of properly performed CPR by the nurse so the nurse may not be sued for malpractice. The insurance company would not settle because the patient did not have a case for malpractice. The patient was not expected to disclose the history of heart disease before collapsing. A history of heart disease does not preclude the patient from going shopping for groceries.

The nurse is caring for a preoperative patient before hysterectomy surgery. The patient tells the nurse that she plans to have lots of children in the future and is glad that the surgery won't keep her from getting pregnant in the future. Which is the best action of the nurse? a. Continue preparing the patient for the upcoming surgery. b. Contact the operating room and cancel the patient's scheduled surgery. c. Inform the surgeon so the patient can be provided with more information. d. Explain to the patient that the surgery will make her unable to get pregnant.

ANS: C The nurse should inform the surgeon so the patient can be provided with more information. The patient does not understand the surgery to be performed as she thinks pregnancy will still be an option afterward. Obtaining informed consent is the responsibility of the surgeon so the nurse should not explain to the patient that pregnancy will not be possible after the surgery. The nurse should not continue the preoperative preparations as the patient is not informed

Which assessment finding leads the nurse to add risk for poisoning to the patient's care plan? a. The patient takes alprazolam 0.25 mg every 8 hours. b. The patient rinses with a fluoride mouthwash after brushing the teeth. c. The patient takes acetaminophen 1000 mg every 4 hours around the clock. d. The patient frequently uses an alcohol-based sanitizer for hand hygiene.

ANS: C The safe maximum daily dosage of acetaminophen is 4000 mg daily. The patient is taking 6000 mg daily, leading to a risk of poisoning. The patient is taking an appropriate dosage of alprazolam daily. Use of fluoride mouthwash daily and an alcohol-based sanitizer for hand hygiene do not put the patient at risk of poisoning.

Which is the appropriate disposal method for used insulin syringes at home? a. Engage the safety cap over the needle and place it in the recycle bin. b. Remove the needle from the syringe and then flush it down the toilet. c. Place the used syringes in a sharps container that is mailed back for destruction. d. Place the used needles in a plastic can that is placed in the center of the trash bin.

ANS: C The safest method is to place the used syringes in a sharps container that is mailed back for destruction. The next best option is to place the used needles in a coffee can (not a plastic can) that is placed in the center of the trash bin. This will help protect sanitation workers from needlestick injury. Syringes and needles should never be flushed down the toilet. Individual syringes should never be placed in the trash even if the safety cap is engaged.

Even though immunization injections are momentarily painful to the patient, they are recommended because they will protect the community from infectious diseases. Which ethical system supports this practice? a. Duty ethics b. Deontology c. Utilitarianism d. Situation ethics

ANS: C Utilitarianism guides us to measure the effect, or consequences, that an act will have. The greatest good for the greatest number of people is the guiding principle for action in this system. By comparison, deontology focuses less on consequences and looks to the presence of pure principles of autonomy, justice, fidelity, beneficence, and nonmaleficence. Situation ethics considers the unique characteristics of an individual person or situation in order to reach the most ethical decision.

Which ethical principle is upheld when the nurse refuses to administer a placebo pill to the patient? a. Justice b. Culture c. Veracity d. Competency

ANS: C Veracity is telling the truth. The nurse upholds the ethical principle of veracity by refusing to administer a placebo pill to the patient. Competency refers to the ability to perform a procedure to the accepted standard. Culture beliefs and values of the group. Justice refers to the principles of fairness.

Which action by the nurse is an example of a legal issue rather than an ethical principle? a. Failing to shut the door completely when bathing the patient b. Providing lower doses of pain medications to patients with red hair c. Working as a registered nurse without a current nursing license d. Deciding not to stop and provide medical care at an accident scene

ANS: C Working as a registered nurse without a current nursing license is a legal issue rather than an ethical issue. Failure to provide privacy violates the ethical principle of confidentiality. The ethical principle of justice is violated when redheaded patients are given lower doses of pain medication. Deciding not to stop and provide medical care at an accident scene violates the ethical principle of beneficence.

A nurse prepares to teach the patient about strategies to minimize feelings of powerlessness. Which techniques will the nurse implement that are the best for this type of learning? (Select all that apply.) a. Lecture b. Practice c. Discussion d. Role play e. Return demonstration

ANS: C, D Teaching methods for affective learning include role play and discussion. Lecture is effective for cognitive learning. Practice and return demonstration are best for psychomotor learning.

The nurse is caring for a patient who climbed out of bed and fell to the floor. What will the nurse do in regard to the incident report? (Select all that apply.) a. Include a recommendation for fall prevention interventions. b. Note in the patient's chart that an incident report was completed. c. Document how the patient was found and a description of the injuries. d. Indicate that the nursing assistant wasn't paying attention to the patient. e. Document fall prevention steps that were in place before the patient fell.

ANS: C, E The nurse will document how the patient was found and a description of the injuries. The nurse will also document fall prevention steps that were in place before the patient fell in order to aid the investigation into the event. The nurse will not suggest that the nurse assistant was not paying attention, chart that an incident report was completed, or make recommendations for fall precautions.

Which is the appropriate intervention for a patient with the nursing diagnosis wandering related to disorientation, memory loss, and urge incontinence? a. Raise three of the four side rails on the patient's bed. b. Assign the patient to a room close to the nursing station. c. Remind the patient to always ask for help before getting up. d. Place a bed alarm to notify staff when the patient is getting up.

ANS: D Alarm devices warn nursing staff that a patient is attempting to leave a bed or chair unassisted. Staff can then provide assistance before the patient is fully out of the bed. Although moving the patient to a room closer to the nursing station allows the nurse to keep a closer eye on the patient, this action does not discourage wandering behavior. Raising side rails has the potential to trap parts of the patient's body, producing a hazard. The use of side rails alone for a disoriented patient often causes more confusion and further injury. Reminders are not effective for this patient due to memory loss.

Which example demonstrates a breach of confidentiality and a violation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996? a. Giving a report to the oncoming nurse in a conference room b. Discussing a patient's diagnosis with the patient's health care provider c. Providing patient information to the nursing assistant caring for the patient d. Sharing a patient's diagnosis and prognosis with other nurses in the cafeteria

ANS: D Although HIPAA does not require things such as soundproof rooms in hospitals, it does mandate that nurses and health care providers avoid discussing patients in public hallways and provide reasonable levels of privacy in communicating with and about patients in any matter. Issues of disclosure, privacy, and confidentiality are important concerns when working with patients or peers infected with bloodborne illnesses such as human immunodeficiency virus (HIV) or acquired immunodeficiency virus (AIDS), hepatitis, and sexually transmitted illnesses. Providing continuity of care, giving reports, talking to the health care provider, and providing information to the nursing assistant do not violate HIPAA.

Which ethical principle is upheld when the registered nurse provides medical assistance to victims of an accident? a. Veracity b. Fidelity c. Autonomy d. Beneficence

ANS: D Beneficence refers to helping others. The nurse demonstrates this by providing medical assistance to victims of an accident. Autonomy is the right to personal freedom. Fidelity is keeping promises and veracity is telling the truth.

The patient sued the hospital for malpractice after developing a postoperative DVT and PE. The nurse's notes did not state that TED hose and sequential compression devices (SCDs) were applied even though they were ordered. Why did the court rule in favor of the patient in the case? a. DVT and PE can develop even if TED hose and SCDs are applied. b. The patient was informed that DVT and PE are known surgical risks. c. The nurse testified that SCDs and TED hose were applied as ordered. d. The nurse failed to document that TED hose and SCDs were applied as ordered.

ANS: D Documentation of nursing care is the only record of what actually was done for a patient and will serve as proof that a nurse acted reasonably and safely. Nursing notes written at the time of the event are seen as better evidence of the facts of the event than any one person's memory. Failure to document application of TED hose and SCDs as ordered violates the nursing standard of careful, complete charting of patient care. Oral testimony of the nurse is not as reliable as written documentation. The nurse's testimony that the SCDs and TED hose were applied might have led the court to find in favor of the nurse. The patient's informed consent did not lead the court to find in favor of the patient in the malpractice trial. DVT and PE can develop even if TED hose and SCDs are applied but the nurse's failure to document application of TED hose and SCDs led the court to rule in favor of the patient.

Providing assistance to which victim would be covered under the state's Good Samaritan law? a. The unit secretary at the hospital suffers an anaphylactic reaction after eating nuts as a morning snack. b. A patient has a grand mal seizure in the hospital foyer when saying goodbye to his family. c. A patient at the clinic where the nurse is working suffers a cardiac arrest after walking in the door. d. Two people are badly hurt in a car accident on the nurse's way to work in the morning

ANS: D Good Samaritan laws encourage health care professionals to provide aid in case of emergencies outside of the workplace. An example of this would be two people who are badly injured in a car accident on the nurse's way to work. The nurse is legally bound to provide care to patients in the workplace. Providing assistance to another hospital employee is not covered under the Good Samaritan laws.

When is the nurse covered by the health care agency's malpractice insurance? a. While caring for scouts at summer camp b. When providing first aid at a car accident c. While assisting a fellow passenger on a flight d. While providing care to patients in the agency

ANS: D If a nurse works for a health care institution, generally the institution's insurance will cover the nurse during employment. The nurse is not covered by the agency's malpractice insurance when volunteering at a scout camp. The nurse will need to carry additional insurance for this situation. Providing assistance on a flight or at the scene of a car accident may be covered by the state's Good Samaritan law.

The nurse is caring for a patient who attempted to get out of bed and fell to the floor, causing a fractured hip. The nursing supervisor asks the nurse to rewrite her entry into the patient's chart to show that the patient's bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Ask the nursing assistant to chart that the patient's bed was lowered to the floor before the patient fell. c. Ask the nursing assistant if the patient's bed was lowered to the floor at the time of the fall. d. Remind the nursing supervisor that it is against regulations to alter or falsify the patients chart

ANS: D It is against the standards of nursing care to alter or falsify information in the patient's chart. The nurse should not ask the nursing assistant to chart that the patient's bed was lowered either.

Which is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet? a. Encourage the patient to participate in tai chi exercises to promote balance. b. Instruct the patient to wear a medical alert bracelet that identifies risk for falls. c. Evaluate the patient's blood pressure for orthostatic hypotension. d. Teach the patient to wear low-heeled, comfortable, supportive footwear at all times.

ANS: D It is essential for patients with diabetic neuropathy to wear supportive footwear at all times to prevent injury to the feet. Patients with neuropathy will not realize if the foot has been injured or punctured, leading to the risk of ulceration, serious wound, or even amputation. Tai chi exercises are not a priority. Fall alert bracelets may be worn in the hospital but are not appropriate for use at home. There is no need to check the patient for orthostatic hypotension.

A small amount of mercury was spilled on the floor after an old sphygmomanometer was broken. What is the priority action of the nurse? a. Disinfect the area with a solution of chlorine bleach. b. Contact the housekeeping staff to mop up the liquid. c. Wipe up the liquid using paper towels and nitrile gloves. d. Consult the agency's materials safety data sheets (MSDS).

ANS: D Mercury is a toxic chemical so the nurse should consult the MSDS to determine how the spill should be cleaned. Mercury cannot be mopped up by a housekeeper or wiped with paper towels. The area should not be disinfected with chlorine bleach.

Which patient learning goal is measurable? a. The patient will understand the importance of daily iron supplements. b. The patient will be able to learn sufficient information to be discharged. c. The patient will feel comforted by the nurses' presence during anxious periods. d. The patient will verbalize responsibility for obtaining daily weights each morning.

ANS: D Patient care plan goals must be measurable so that the nurse can determine whether or not the goal has been met. Measurable goals use objective terms such as verbalize, demonstrate, list, articulate, and perform. The patient's verbalization of responsibility for obtaining daily weights each morning is a measurable goal. The nurse cannot objectively determine if the patient understands, feel comforted, or learn sufficient information in order to determine whether or not the goal has been achieved.

The nurse includes "The patient will demonstrate correct technique for self-injection of insulin" as a goal in the patient's care plan. Which type of learning is addressed by this goal? a. Cognitive b. Affective c. Perceptive d. Psychomotor

ANS: D Psychomotor learning is the acquisition of motor skill such as injection of insulin. Cognitive learning is thinking in new ways. Affective learning is expression of emotions or beliefs. Perceptive means the ability to sense of show insight.

Which is the first action of the nurse when teaching the patient how to perform colostomy care? a. Determine the patient's educational background and learning abilities. b. Identify a responsible family member to reinforce colostomy care teaching. c. Have the patient watch a video that demonstrates how to perform colostomy care. d. Assess the patient's level of comfort with looking at and caring for the colostomy.

ANS: D The first action of the nurse is to determine the patient's readiness to learn about colostomy care. The nurse should assess the patient's level of comfort with looking at and caring for the colostomy before initiating any teaching. Identifying a family member to assist, determining the patient's educational background, and having the patient watch a video should all be done after assessing the patient's readiness to learn.

Which approach will be most successful for the nurse to teach a preschooler about tube feeding through a gastrostomy tube? a. Offer opportunities to discuss tube feeding options and answer questions. b. Hold the child while smiling and speaking softly to convey a sense of trust. c. Collaborate with the child to develop an individualized tube feeding schedule. d. Use simple terms and show the child a gastrostomy tube inserted into a teddy bear.

ANS: D The nurse should allow the child to see and touch a gastrostomy tube inserted into a teddy bear to facilitate teaching about tube feeding. Holding the child while smiling is an appropriate teaching technique for an infant. The preschooler is not mature enough to develop an individualized tube feeding schedule or discuss tube feeding options.

Which is the best method to begin teaching the adult patient how to self-administer tube feeding through a new gastrostomy tube? a. Analogies b. Detachment c. Role play d. Demonstration

ANS: D The nurse should begin to teach the patient by demonstrating how to administer tube feedings. The patient is then encouraged to assist until a return demonstration of the skill can be performed. Detachment is not a teaching approach. Role playing and analogies are not appropriate for teaching tube feeding administration.

Which sentence is appropriate to write in an incident report for a patient who got out of bed and fell? a. The patient probably urinated on the floor and slipped due to the wet floor. b. The patient's nurse assistant always takes forever to answer patient call lights. c. The patient never follows directions and always causes trouble for the nurses. d. The patient was found lying on the floor with his urinal on the floor next to him.

ANS: D The nurse will objectively record the details of the event and any statements the patient makes including how the patient was found on the floor. The nurse should not attempt to blame the patient or other staff members for the incident. The nurse should not make conjectures about how the incident occurred.

Which ethical principle is upheld when the surgeon refuses to operate on the patient because potential benefit is minimal compared to the pain that the patient will endure? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

ANS: D The principle of nonmaleficence (do no harm) promotes a continuing effort to consider the potential for harm even when it is necessary to promote health. It is helpful in guiding your discussions about new or controversial technologies. Autonomy deals with independence and self-determination. Justice refers to fairness or equity of health care resources. Fidelity refers to maintaining promises and faithfulness.

Which statements demonstrate that the patient is at the acceptance stage of learning? (Select all that apply.) a. "I do not have to learn how to do the dressing. My wife will do it for me." b. "I feel like such a failure for not consulting a podiatrist earlier about my foot." c. "I'll try to do the exercises you described if you will give me a cookie afterward." d. "I want to learn how to do this myself so I do not have to go to a rehab center." e. "I know that I have to give myself the injections because I could get a blood clot."

ANS: D, E The patient indicates acceptance by wanting to learn and understanding the importance of the teaching. Referring the care to the spouse, feeling like a failure, and wanting rewards do not demonstrate acceptance.

Which action by the nurse will best allay a young child's fear about auscultation of breath sounds? a. Do nothing because the more fuss that is made about a procedure, the more anxiety it causes the patient. b. Explain to the patient that the stethoscope is used to listen to air going in and out of the lungs. c. Allow the child to listen to sounds with the stethoscope before the nurse uses it for assessment. d. Ask the child's mother to step outside the room because children frequently do better when alone.

an:c Describe physical sensations that will occur during the procedure by telling the child that the stethoscope will not hurt. Providing information about procedures helps patients feel less anxious because they understand what to expect during the procedure. When preparatory instructions accurately describe the actual experience, the patient is able to cope more effectively with the stress from procedures and therapies. Doing nothing does not prepare the patient properly or address the anxiety. Involve the parents with young children.

A nurse tells a patient with a recent back injury that damage to the nerves is comparable to a water hose that has been pinched off and that time is needed to allow normal nerve transmission. Which technique did the nurse use? a. Analogy b. Discovery c. Role playing d. Demonstration

ans a Analogies add to verbal instruction by providing familiar images that make complex information more real and understandable. Discovery is a useful tool for teaching problem solving and is a technique for cognitive learning. During role play your patients play themselves or someone else in the situation. Demonstrations are useful when teaching psychomotor skills.

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room? a. American Association of Poison Control Centers b. Centers for Disease Control and Prevention c. Agency for Healthcare Research and Quality d. Institute for Safe Medication Practices

ans a The American Association of Poison Control Centers supports the Poison Help Line and should be contacted for information about acetaminophen overdose. The CDC manages infectious diseases. The AHRQ conducts research about health care practices. The ISMP promotes safe administration of medications by practitioners.

Into which seating position will the nurse teach a family to place their 18-month-old toddler in the family car? a. Front seat facing backward b. Rear seat facing backward c. Front seat facing forward d. Rear seat facing forward

ans b

The wrong type of medication was administered to the patient. Which type of error is this? a. Exposure-related accident b. Procedure-related accident c. Equipment-related accident d. Organization-related accident

ans b A procedure-related accident is caused by health care providers and includes medication and fluid administration errors, not putting external devices on correctly, and improperly performing procedures such as dressing changes. An equipment-related accident results from misuse, disrepair, malfunction, or electrical hazard. There is no classification of exposure-related accident or organization-related accident.

The nurse is directed to take an unsafe patient assignment. What is the most appropriate first action of the nurse? a. Contact the State Board of Nursing. b. Contact the nursing supervisor on duty. c. Contact the hospital administrator on call. d. Refuse to accept the assignment and leave.

ans b If a nurse is assigned to care for more patients than is reasonable for safe care, the appropriate first action is to contact the nursing supervisor. If the nurse is required to accept the assignment, he or she must document this information in writing and provide the document to nursing administrators. Although documentation does not relieve a nurse of responsibility if patients suffer harm because of inattention, it shows that the nurse attempted to act appropriately. Refusing to care for the patients without appropriate help and leaving could be regarded as abandonment. Complaining to the administrator is not the first step, nor is calling the Board of Nursing.

Which is the highest priority nursing diagnosis for a college student who is living away from home for the first time? a. Sleep deprivation related to noisy dormitory environment b. Risk-prone health behavior related to weekend binge drinking c. Relocation stress syndrome related to moving away from home d. Risk for loneliness related to being away from family and old friends

ans b Weekend binge drinking indicates a risk-prone health behavior that could lead to liver damage, injury, or death. Sleep deprivation is not as important as binge drinking. Relocation stress syndrome and risk for loneliness relate to psychosocial needs, making these diagnoses lower priority than physical need for safety and rest.

Which is an example of a procedure-inherent accident? a. The patient suffered a burn due to a malfunctioning heating pad. b. The patient suffered a tongue laceration during a grand mal seizure. c. The nurse suffered a back injury when repositioning a heavy patient in bed. d. The physician suffered a broken wrist after it was caught in the elevator door.

ans c A procedure-inherent accident occurs when a patient or staff member is injured in the process of providing patient care. An example of a procedure-inherent accident is a back injury caused by moving a heavy patient in bed. A malfunctioning heating pad caused an equipment-related accident. A tongue laceration from a seizure is a patient-inherent accident. A broken wrist in an elevator door could be considered an equipment-related accident.

Which ethical principle is violated when the nurse promises to administer pain medication to the patient every 2 hours throughout the shift and then fails to do so? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

ans c Fidelity refers to the agreement to keep promises. The principle of fidelity also promotes the obligation of a nurse to follow through with the care offered to patients. Autonomy refers to independence and self-determination, which is what the patient followed, but the question asked for which principle the nurse followed. Justice refers to fairness or equity of health care resources. Nonmaleficence refers to the fundamental agreement to do no harm.

The nurse is at the shopping mall when the sales clerk collapses in cardiac arrest. The nurse assists the victim and performs CPR until the paramedics arrive. Which action by the nurse could lead to a malpractice suit even though the state has a Good Samaritan law? a. The nurse went to visit the victim in the hospital the following day. b. The nurse accepted a small gift from the store in appreciation for her help. c. The nurse sent a bill to the victim to request payment for services rendered. d. The nurse provided both chest compressions and rescue breathing for the victim.

ans c Good Samaritan laws cover health care professionals who voluntarily provide aid in emergency situations. The nurse is no longer protected by the state's Good Samaritan law if a bill is sent to the victim to request payment for services rendered. The nurse is allowed to accept a small gift from the store in appreciation but cannot accept cash payment of any kind in order to be covered by the state's Good Samaritan law. There is nothing wrong with the nurse visiting the patient the next day. CPR guidelines call for rescue breathing and chest compressions.

The patient keeps more than 30 cats in the home and is unable to adequately care for them. Which is the priority nursing diagnosis for this patient? a. Disturbed sensory perception related to inability to smell cat feces b. Caregiver role strain related to inability to adequately care for 30 cats c. Impaired home maintenance related to unhygienic, unclean surroundings d. Risk for situational low self-esteem related to neglected home environment

ans c Impaired home maintenance related to unhygienic, unclean surroundings is the priority nursing diagnosis because the unhygienic conditions can lead to illness, injury, or infection. The inability to smell cat feces is not as important as the overall impaired home maintenance. Caregiver role strain is not appropriate for this patient. Risk for situational low self-esteem is not a high priority.

After a massive earthquake, the emergency room staff focuses to provide care to the patients who are likely to survive rather than expending maximum effort on a few critically injured patients. Which ethical theory is demonstrated in this situation? a. Deontology b. Feminist ethics c. Utilitarianism d. Ethics of care

ans c Utilitarianism determines the value of something based primarily on its usefulness and benefit for the greater good. In this case, the emergency room staff focuses on saving the many rather than working to save the few. Deontology defines actions as right or wrong according to principles. The feminist ethic asks how ethical decisions will affect women. The ethics of care suggests that health care workers solve ethical dilemmas by the promotion of the fundamental act of caring.

Which ethical principle is violated when the nurse is overhead talking about the patient's prognosis in the elevator? a. Judgment b. Advocacy c. Accountability d. Confidentiality

ans d Confidentiality is the protection of patient information so that it is not shared with others. The nurse violated the ethical principle of confidentiality when the patient's prognosis was overhead in the elevator. Judgment refers to the ability to make appropriate decisions based on the situation. Advocacy refers to the nurse's responsibility to speak up for and protect the rights of patients. Accountability means that the nurse must be responsible for actions and decisions.

What is the primary difference between negligence and malpractice? a. Malpractice is intentional while negligence is unintended. b. Malpractice is a felony while negligence is a misdemeanor. c. Malpractice leads to more serious patient injury than negligence. d. Malpractice is committed by a licensed professional while negligence is not.

ans d Malpractice may sometimes be referred to as professional negligence. Negligence occurs when the level of care provided to the patient falls below the generally accepted standard. When negligence is committed by a licensed professional, it is termed malpractice. Malpractice may be intentional or unintended. Malpractice may be considered a felony or a misdemeanor depending on the circumstances. Both negligence and malpractice can lead to serious patient injury.

Which is the most appropriate learning goal for new parents who are learning infant CPR? a. The parents will demonstrate infant CPR skills. b. The parents will be able to understand CPR skills. c. The infant will not require further hospitalization. d. The parents will call the hospital if the infant stops breathing.

ans: a A learning objective describes what the patient or guardian(s) will be able to do after successful instruction. The objective contains an active verb describing what the learner will do after the objective is met (demonstrate). Understand does not specify the behavior or content to be learned and is not an active verb. The parent's "understanding" is not measureable, and learning goals need to be measureable. The best learning goal in the case of a skill is to demonstrate that skill. The learning objectives should focus on the parents as they are the learners; it should not focus on the infant. The parents should call the hospital for help but this does not relate to the skill being taught, CPR.

The family is unsure what treatment is appropriate for the comatose patient who is terminally ill. Which steps will the nurse take to help the family process this ethical dilemma? (Select all that apply.) a. Consider all possible treatment options. b. Calculate the odds of the patient's survival. c. Clarify own values and opinions about the issues. d. Provide personal opinions about treatment options. e. Gather all relevant information about the situation.

ans: a,c,e The nurse should gather all relevant information, clarify own values and opinions about the issue, and consider possible courses of action. Seven steps are used when solving an ethical dilemma: (1) Asking "is it an ethical dilemma?", (2) gathering all information, (3) examining and determining one's own values and opinions about the issue, (4) stating the problem clearly, (5) considering possible courses of action, (6) negotiating an outcome, and (7) evaluating the action. Calculating the odds of the patient's survival and providing personal opinions about treatment options are not steps of the process.

Which organization will discipline the nurse for abandoning patients during an assigned shift? a. The Joint Commission b. The State Board of Nursing c. The State Department of Health d. The National League for Nursing

ans: b The State Board of Nursing sets rules, regulations, and guidelines that specifically define the standard of care in nursing practice. An example is the guideline that defines patient abandonment. The State Board of Nursing also investigates allegations of nursing misconduct and disciplines nurses who have failed to comply with the state Nurse Practice Act. The State Department of Health, The Joint Commission, and the National League for Nursing do not set the legal rules and regulations for patient abandonment.

Which actions by the nurse violate the American Nurses Association's Social Media Policy? (Select all that apply.) a. The nurse posts a professional profile on LinkedIn. b. The nurse describes a patient's injury on Facebook. c. The nurse posts opinions about co-workers on Twitter. d. The nurse writes a blog about the need for staffing ratios. e. The nurse posts a picture of a patient's wound on Instagram.

ans: b,c,e The American Nurses Association has developed a Social Media Policy (2011), which recommends that when using social media sites, a nurse should never name or describe a patient, never post an image of a patient, and never disparage a fellow employee or employer. The nurse is allowed to write a blog about staffing ratios and post a professional profile on LinkedIn.