Princeton Review Management of Care Drill 4

The nurse is educating new nurses on the informed consent process. Which statement by the new nurse demonstrates an understanding of the nurse's role in informed consent? Question 20 Answer Choices A“I will sign the consent form as a witness to having seen the patient sign the form.” "I will sign the consent form as a witness to having seen the patient sign the form." B“If the client has any questions, I will answer them before having the client sign the form.” "If the client has any questions, I will answer them before having the client sign the form." C“If the healthcare provider is unavailable, I can conduct the informed consent discussion.” "If the healthcare provider is unavailable, I can conduct the informed consent discussion." D“I do not need to assess the client’s understanding of the procedure before having them sign the document.” "I do not need to assess the client's understanding of the procedure before having them sign the document."

A Rationale: As a nurse, you sign the consent form as a witness to having seen the patient sign the form, not as having obtained the consent yourself. Assess whether patients understand what they are signing and are acting voluntarily and report any concerns to the healthcare provider. Having patients describe in their own words what they understand they are consenting to is the best way to make sure that they understand.

The nurse is caring for a client with an external fixator on the left leg. The unlicensed assistive personnel asks how to bathe the client with this device in place. Which response by the nurse is appropriate? Question 9 Answer Choices A“We need to provide meticulous care to all of the pins, so I will help with that part.” "We need to provide meticulous care to all of the pins, so I will help with that part." B“Please use normal saline and clean around all insertion points.” "Please use normal saline and clean around all insertion points." C“We will avoid touching the left leg altogether as it is immobilized.” "We will avoid touching the left leg altogether as it is immobilized." D“We will need a bottle of chlorhexidine and some gauze for daily pin site cleansing.” "We will need a bottle of chlorhexidine and some gauze for daily pin site cleansing."

A Rationale: External fixation involves the surgical insertion of pins through the skin and soft tissues into and through the bone. A metal external frame is attached to these pins and is designed to hold the fracture in proper alignment to enable healing to occur. The disadvantage of an external fixator is an increased risk for pin site loosening and infection, which can lead to osteomyelitis. Wound care should occur at least daily and include the use of nonshedding gauze. Normal saline can be used, but wound care should be performed by the registered nurse so the assessment may occur. Chlorhexidine is too harsh for daily use and should be used weekly.

The nurse is preparing a 25-year-old client for surgery and asks the client about an advance directive. The client states, "Why do you need to know that? I am young and this is supposed to be a minor surgery." Which response would be appropriate for the nurse to make? Question 16 Answer Choices A“It is required to ask if you have one and provide you with information if you don’t, regardless of age or reason for hospitalization.” "It is required to ask if you have one and provide you with information if you don't, regardless of age or reason for hospitalization." B“The hospital needs to be sure you have made the proper arrangements ahead of time in case anything was to happen to you.” "The hospital needs to be sure you have made the proper arrangements ahead of time in case anything was to happen to you." C“Having an advanced directive in place will give the medical personnel the ability to make decisions for you.” "Having an advanced directive in place will give the medical personnel the ability to make decisions for you." D“The healthcare provider will need to have you complete the advanced directive before you have surgery.” "The healthcare provider will need to have you complete the advanced directive before you have surgery."

A Rationale: The Patient Self-Determination Act requires all clients are asked if they have an advance directive in place to communicate the client's health care wishes. If the client does not have one, the information will be provided with assistance in how to fill one out. An advance directive or living will have to do with health care choices and designating someone to speak for you when you are not able regarding funeral arrangements. Healthcare providers are not given rights to express a client's end-of-life decisions in an advance directive or living will.

Upon walking into a client's room, the nurse observes a family member yelling at the unlicensed assistive personnel. Which action by the nurse is most appropriate? Question 10 Answer Choices AAsk the family member to discuss their concerns with you Ask the family member to discuss their concerns with you BCall facility security to handle the situation Call facility security to handle the situation CCome back to the client’s room at a later time Come back to the client's room at a later time DTell the family member that they need to leave Tell the family member that they need to leave

A Rationale: When a client, family member, or staff member is upset, the most appropriate action by the nurse is to try to deescalate the situation by listening to the person's concerns. Depending on what those concerns are, the nurse can choose their actions more appropriately. Calling security or asking the family member to leave may be necessary if the nurse is unable to deescalate and address the situation. Coming back at a later time does not address the conflict and potentially allows the situation to escalate further.

The nurse is planning the daily care for assigned clients. Which of the following tasks can be delegated to the unlicensed assistive personnel? Question 4 Answer Choices AAssessing a client’s surgical wound Assessing a client's surgical wound BAssisting a client with ambulation Assisting a client with ambulation CRemoving a peripheral IV Removing a peripheral IV DDocumenting medication administration Documenting medication administration

B Rationale: An unlicensed assistive personnel (UAP) cannot assess a client, remove invasive lines (such as an indwelling catheter or IV), or document tasks in the medical record that are out of their scope of practice (medication administration). It is appropriate to ask for a UAP to assist a client with ambulation.

The registered nurse and an experienced licensed practical nurse (LPN/VN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN/LVN? Question 3 Answer Choices AProvide discharge instructions to the spouse of a confused client Provide discharge instructions to the spouse of a confused client BStraight catheterize a client who has not voided in 8 hours Straight catheterize a client who has not voided in 8 hours CDevelop a plan of care for a client who is recovering from an appendectomy Develop a plan of care for a client who is recovering from an appendectomy DComplete the admission assessment for a client with diverticulitis Complete the admission assessment for a client with diverticulitis

B Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated should be based on the training and competence of the individual accepting the delegation. The LPN/LVN scope of practice and training includes performing straight catheterization.

A client with stable angina requests to be discharged from the emergency department. The healthcare provider explains the risks of not receiving medical treatment and refuses to discharge the client. Which action does the nurse perform next? Question 7 Answer Choices AEncourage the healthcare provider to discharge the client Encourage the healthcare provider to discharge the client BContact the nurse manager to speak with the client Contact the nurse manager to speak with the client CAsk the client to sign an against medical advice form Ask the client to sign an against medical advice form DRequest an unlicensed assistive personnel to escort the client out of the facility Request an unlicensed assistive personnel to escort the client out of the facility

C Rationale: Alert, stable, and mentally competent clients have the right to refuse medical care. The nurse must ensure the client understands the risks of refusing medical care and ask the client to sign an against medical advice form before exiting the facility. The nurse respects the client's wishes but does advocate for an unsafe discharge. Escalation of the situation to a nurse manager is not indicated if the healthcare provider has explained the risks to a stable, mentally competent client. A client can be escorted out of the facility if necessary after signing an against medical advice form.

The nurse is caring for a client at end of life whose advance directive states that they do not want food or fluids. The nurse notes a new order for a nasogastric tube with enteral feeding. What action by the nurse is appropriate? Question 19 Answer Choices AInsert the feeding tube Insert the feeding tube BReport the physician to the nurse manager Report the physician to the nurse manager CInform the healthcare provider of the instructions in the advance directive Inform the healthcare provider of the instructions in the advance directive DAsk a colleague to insert the tube Ask a colleague to insert the tube

C Rationale: An advance directive is a legal document that goes into effect if the client is incapacitated and unable to participate in self-determination. One type of directive is a living will that spells out the client's wishes for certain medical treatments, such as resuscitation, ventilation, and tube feeding, etc. The nurse should collaborate with the provider who wrote the order as they may be unaware of the instructions in the advance directive. The nurse is not required to insert the tube and should not ask another colleague to do so. It may be appropriate to report the physician if an ethical dilemma arises, but at this time, this is not appropriate.

The nurse is caring for a client with a history of chronic pain who reports inadequate pain relief from oral analgesics. The client states "I just can't do the things I used to." Which action by the nurse would be most appropriate? Question 5 Answer Choices AObtain a prescription for a higher dose from the health care provider Obtain a prescription for a higher dose from the health care provider BAsk the health care provider to change the analgesic route to IV Ask the health care provider to change the analgesic route to IV CAssess the client’s knowledge of complementary alternative medicine Assess the client's knowledge of complementary alternative medicine DRefer the client to a pain specialist Refer the client to a pain specialist

C Rationale: Client independence is best achieved by assessing the client's knowledge of complementary alternative medicine. This action supports self-care and client participation. An increased dose as well as an alternate route of administration (oral to intravenous) may provide temporary relief but could increase side effects that could limit a client's independence. Referrals may be needed but do not support client measures to manage pain and self-care independently.

A nurse is feeding a client with Parkinson disease. Which nursing observation indicates the client may benefit from a referral to speech therapy? Question 15 Answer Choices AThe client tucks their chin while swallowing. The client tucks their chin while swallowing. BThe client chews the food quickly. The client chews the food quickly. CThe client has drooling of food. The client has drooling of food. DThe client requests food to be pureed. The client requests food to be pureed.

C Rationale: Drooling of food is an indication of possible dysphagia. The client would benefit from a referral to speech therapy for a safety assessment while feeding. Tucking the chin helps to move food down the esophagus and is good practice to prevent aspiration. Chewing the food quickly does not indicate a deficiency. The client requesting food to be pureed is an indication that they understand the risk of aspiration.

The nurse is admitting a client from the postoperative care unit following an appendectomy. Which of the following is the priority for the nurse to assess? Question 12 Answer Choices ASurgical dressing Surgical dressing BPulses Pulses CRespiratory rate Respiratory rate DPain Pain

C Rationale: Frequent and skilled assessment of the client's airway, respiratory function, cardiovascular function, and the ability to respond to commands. The nurse should immediately assess the client's airway upon arrival to the PACU. Assessment of the surgical site, pulses, and pain should all be completed after the airway is deemed stable.

The intensive care unit had an increase in falls from last quarter. To help improve patient outcomes, the nurse recommends including physical therapy during department meetings. Which type of process has the nurse recommended? Question 18 Answer Choices APatient-centered care Patient-centered care BCare mapping Care mapping CInterprofessional collaboration Interprofessional collaboration DCare bundles Care bundles

C Rationale: Interprofessional collaboration involves multiple healthcare disciplines working with clients, families, and communities to improve outcomes. Inviting physical therapy to join the team to invoke change in the unit is an example of this form of collaboration. Patient-centered care is focused care plans based on the client's specific outcomes. Care mapping is a form of evidence-based practice in the form of clinical guidelines. Care bundles are used in the acute care setting, and many of them are a part of the nurses' scope of practice and can be implemented once the bundle is ordered by the healthcare provider.

A pediatric client is seen by the school nurse who notices several deep, round wounds with well-defined edges that resemble cigarette burns. The client reveals that a caregiver has been abusive. What is the nurse's first responsibility in caring for this child? Question 17 Answer Choices AInform the other caretaker of the injuries Inform the other caretaker of the injuries BNotify law enforcement Notify law enforcement CNotify Child Protective Services Notify Child Protective Services DDocument all the areas of injury Document all the areas of injury

C Rationale: Nurses are mandated reporters of abuse and, as such, are required to notify the state's child protective services department. It is not mandated that the reporter notify the caregivers that a report has been filed. It is also not necessary to notify the police unless the client is in immediate danger. Child protective services will involve law enforcement as needed. All areas of injury should be documented, but the child's safety is the priority intervention.

A nurse is providing care to a client who is on a ventilator following a stroke. The client's spouse is denying consent to several prescribed medical interventions. Which action does the nurse perform next? Question 2 Answer Choices AFollow the wishes of the client’s spouse Follow the wishes of the client's spouse BPerform the medical interventions as prescribed Perform the medical interventions as prescribed CNotify the client’s primary healthcare team Notify the client's primary healthcare team DDocument refusal of care in the client’s medical record Document refusal of care in the client's medical record

C Rationale: The nurse advocate must act in the best interest of the client and notify the primary healthcare team. The spouse's lack of consent to medical interventions may harm the client and the reasons for refusal should be assessed. The nurse must continue to be the client's advocate despite the inability to communicate with the client. Performing the medical interventions will cause mistrust in the client's spouse. Documenting the refusal of care is an important intervention. However, the nurse must first advocate for the client's medical care

A nurse is providing care to a client with a do not resuscitate (DNR) advance directive. The nurse enters the client's room and finds the client unresponsive in bed. Which action does the nurse perform next? Question 1 Answer Choices AInitiates chest compressions Initiates chest compressions BApplies supplemental oxygen to the client Applies supplemental oxygen to the client CChecks the client’s pulse Checks the client's pulse DContacts the healthcare provider Contacts the healthcare provider

C Rationale: The nurse checks the client's pulse to confirm the absence of circulation. Although the client has a do not resuscitate (DNR) advance directive, the nurse must still confirm the client's condition. Initiating chest compressions goes against the client's advance directive. Applying supplemental oxygen to the client provides comfort measures. However, the nurse must first confirm the client is unresponsive. Contacting the healthcare provider is an important intervention after the nurse confirms the client's condition.

The nurse is caring for a pediatric client who is being evaluated for cystic fibrosis. When collecting data to develop a plan of care, the nurse should give priority to which finding? Question 6 Answer Choices ACaregiver states stools are bulky and greasy Caregiver states stools are bulky and greasy BWeight of client is below the 50th percentile on the growth chart Weight of client is below the 50th percentile on the growth chart CCaregiver reports frequent history of recurrent respiratory infections Caregiver reports frequent history of recurrent respiratory infections DActivity intolerance and fatigue are reported with exercise Activity intolerance and fatigue are reported with exercise

C Rationale: The nurse should give priority to respiratory issues (ABCs) in the plan of care of a client with a possible diagnosis of cystic fibrosis. Due to the genetic dysfunction of the protein CFTR, the transport of chloride across the cellular membrane is disrupted resulting in thick tenacious secretions in the lungs and digestive tract. Due to malabsorption, stools may be bulky and greasy in nature. Malabsorption issues may also result in weight loss and failure to thrive. Activity intolerance and fatigue reported with exercise are related to respiratory complications of this disease.

A day-shift nurse is performing rounds on several clients. Two of the clients tell the nurse that the night-shift nurse did not come into their room all night. The nurse reviews the clients' records and observes multiple progress notes by the night-shift nurse. Which action should the nurse take? Question 14 Answer Choices AShow the clients the progress notes written by the night-shift nurse Show the clients the progress notes written by the night-shift nurse BRefer the clients' concerns to customer service Refer the clients' concerns to customer service CInform the nurse manager of the clients’ statements Inform the nurse manager of the clients' statements DAsk the rest of the clients if they have any concerns about their care Ask the rest of the clients if they have any concerns about their care

C Rationale: The nurse should inform the nurse manager of the clients' statements. Multiple concerns regarding lack of nursing care should be referred to a supervisor for follow-up. Showing the clients the progress notes written by the night-shift nurse is not appropriate. The nurse may be falsifying documentation and require an investigation by a supervisor. Referring the client's concerns to customer service is not indicated unless the unit supervisor is aware of the situation. The nurse must follow the chain of command. Asking the rest of the clients if they have concerns about the care received is not the nurse's responsibility in an ethical dilemma.

An unresponsive client arrives at the emergency department after sustaining a fall from a ladder. Which action will the nurse perform first? Question 13 Answer Choices AAuscultate the client’s bilateral breath sounds Auscultate the client's bilateral breath sounds BInitiate peripheral intravenous access Initiate peripheral intravenous access CPerform a modified jaw thrust maneuver Perform a modified jaw thrust maneuver DAdminister prescribed pain medication Administer prescribed pain medication

C Rationale: The nurse's priority is to establish the client's airway. A client who is unresponsive after trauma may have cervical spine injuries. The nurse performs a modified jaw thrust maneuver to safely open the client's airway. Auscultation of the client's breath sounds should be performed after the nurse verifies the client's airway is secured. Initiating peripheral intravenous access restores circulation, which should be assessed after airway and breathing. The administration of pain medication should be performed after the nurse completes the primary survey.

A nurse is providing care to an older adult client with newly diagnosed cancer. The client's family tells the nurse, "We aren't sure about pursuing treatment; no one in the family has the resources to care for our loved one at home." Which action does the nurse perform? Question 8 Answer Choices AContacts the healthcare provider to inform them of the family’s decision  Contacts the healthcare provider to inform them of the family's decision BRefers the case to the ethics committee for review Refers the case to the ethics committee for review CCalls the nurse supervisor to report refusal of care Calls the nurse supervisor to report refusal of care DRequests a consult to case management for care coordination Requests a consult to case management for care coordination

D Rationale: Case managers can assist the client and their family with resources for treatment and post-discharge arrangements. The nurse requests a consult with case management to assist the client's family with the client's care. Contacting the healthcare provider regarding the family's decision does not advocate for the client. An ethics committee and notifying the nurse supervisor are not indicated at this time. The nurse must first refer the client's family to a care coordinator for assistance.

A nurse is working with a graduate nurse. The graduate nurse provided information to a caller who identified themself as the client's spouse. After informing the client that their spouse had been given an update, the client stated, "What? I'm not married." What is the initial action by the nurse? Question 11 Answer Choices AAsk the client to provide a code for disclosure of health information Ask the client to provide a code for disclosure of health information BReport the incident to the healthcare provider Report the incident to the healthcare provider CReview policies for handling confidential patient information Review policies for handling confidential patient information DComplete an incident report Complete an incident report

D Rationale: The initial action of the nurse is to be accountable for the breach of confidentiality and complete an incident report as per protocol. Because of the breach of confidentiality, HIPAA protocol and policies for handling confidential patient information should be reviewed, but it is not an initial action of the nurse. In addition, an initial action of the nurse would not be to report the incident to the healthcare provider. For future protection of patient information, it is important that the client identifies those with who their health information may be shared. Many patients don't consent to give their family members updates on their condition. In addition, the use of a password or code may be incorporated to protect confidential client information.