Unit 3 Test: HIT, PCC, Healthcare Organizations

A home care nurse visits a client with muscular dystrophy. Which comment by the client indicates that he needs more information about an advance directive?

"I love apple pie. I don't ever want a feeding tube when the time comes that I can't eat."

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply.

1. Maintain integrity and shape social policy. 2. Develop, maintain, and improve health care environments. 3. Be responsible and accountable for individual practice. 4. Increase professional competence and personal growth.

The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who: Select all that apply.

1. has episodes of vertigo that result in falls. 2. has multiple sclerosis with an open, draining lesion on a foot.

The pediatric nurse is being pulled to the nursery for the day. The census is six neonates. Which three neonates are the best client care assignment for the pediatric nurse?

A recent admission with Apgar score of 8 and 10. A one-day-old with caput succedaneum A 4-hour-old with a bluish appearance to the hands and feet

A client has been prescribed a narcotic analgesic to be given around the clock for cancer-related pain. The client is competent and has actively been involved in decisions regarding care. What should the nurse do when the client refuses the next dose of pain medication?

Document the client's choice and reassess the pain in 1 hour.

A public health nurse is working in a community immunization clinic. Client information gathered at the clinic is stored and transported to the health unit on a portable memory device. Which of the following must the nurse do to protect the confidentiality of the information?

Ensure that the information on the memory device is protected.

The nurse is preparing for the admission of a client on a stretcher. In what position should the nurse place the bed?

Highest position

A nurse caring for a client being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

Information is documented in separate forms by each health care professional.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?

Narrative notes.

A client has signed a document indicating a wish not to be resuscitated. During morning rounds, the nurse finds the client without vital signs. What is the most appropriate action for the nurse to take?

Notify the physician that the client has no vital signs.

A nurse is caring for a 15-year-old male recently diagnosed with osteosarcoma of the right femur with lung metastasis. He and his visiting parent are discussing their uncertainty about the need for surgery or other therapies. How can the nurse best demonstrate the advocacy role?

Notify the physician to meet with the family.

A nurse is caring for a client at the local health care facility. Which of the following ensures that legislation related to client confidentiality is implemented at the facility?

Place in private areas light boxes for examining x-rays with the client's name.

To prevent the spread of infection in the home healthcare environment, the nurse should follow appropriate technique by:

Placing equipment back on a liner when setting it down in the client's home.

S O A P

Subjective Obj. Assessment Plan

A health care provider (HCP) is calling the pediatric unit and asking the nurse to go into the medical record for test results of a fellow pediatrician. How should the nurse respond to this request?

Verify that the caller is the HCP of record or has a need to know.

The nurse is caring for a client, newly diagnosed with cancer, who speaks limited English. The client's family speaks limited English also and a friend drives him to his doctor's appointments. The nurse selects Deficient knowledge as a priority. Which nursing interventions are appropriate? Select all that apply.

Work with an interpreter to discuss the situation. Assess any community resources for support groups and communication Obtain a "type to speak" computerized translation dictionary to express information Obtain common pictures to provide a common ground for understanding

Autonomy

ability of client to make personal decisions, even when those decisions may not be in the client's best interest

Benefience

agreement that the care given is in the best interest of the client; taking positive actions to help others

Fidelity

agreement to keep one's promise to the client about care that was offered

A nurse is serving on a task force to update the electronic health record. The task force should ensure that revisions of the medical record will: (Select all that apply.)

aid in client care. serve as a legal document. facilitate data collection for clinical research. guide performance improvement.

Nonmalefience

avoidance of harm or pain as much as possible when giving treatments

After many years of advanced practice nursing, a nurse has recently enrolled in a nurse practitioner (NP) program. This nurse has been attracted to the program by the potential after graduation to provide primary care for clients, an opportunity that is most likely to exist in which of the following settings?

A rural health center.

For a hospitalized client, the physician orders morphine, 4 mg I.V., every 2 hours as needed for pain. However, the client refuses to take injections. Which nursing action is most appropriate?

Calling the physician to request an oral pain medication

The nurse recognizes that discharge planning begins upon admission and the initial step in discharge planning is:

Collecting and organizing data about the client.

The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, what should the nurse do?

Consult the drug guide provided by the clinical agency.

The health care team has noticed an increase in IV infiltrations on the pediatric floor. As part of a Plan, Do, Study, Act quality improvement plan the team should perform the actions in which order? All options must be used.

Decide to monitor IV gauges. Perform chart audits. Analyze the data. Write a new IV insertion policy.

In anticipation of discharge, a nurse is teaching the daughter of an elderly woman how to change the dressing on her mother's venous ulcer. Which of the following teaching strategies is most likely to be effective?

Demonstrate and explain the procedure, and then have the daughter perform it.

After several years of providing bedside care in an inpatient setting, a nurse has taken a position with the state board of nursing. In this role, the nurse may contribute to which of the following activities of a state board of nursing?

Issuing and transferring nursing licenses within the state

During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth.

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client?

Recognize and address the client's anxiety.

The children of a 78-year-old female client with a recent diagnosis of early-stage Alzheimer's disease are attempting to convince their mother to move into an assisted living facility, a move to which the client is vehemently opposed. Both the client and her children have expressed to the nurse how they are entrenched in their position. Which of the following statements expresses a utilitarian approach to this dilemma?

The decision should be made in light of consequences.

A client states, "I do not want any more tests. Who cares what kind of leukemia I have? I just want to be treated now." Which is the nurse's best response?

Your treatment can be more effective if it is based on more specific information about your disease."

Two days after an ileostomy, the client refuses care and requests to be left alone. The nurse should first:

encourage the client to verbalize feelings.

A community health nurse working with a group of 5th grade girls is planning a primary prevention to help the girls avoid developing eating disorders during their teen years. The nurse should focus on which factor?

helping the girls accept and appreciate their bodies and feel good about themselves

The nurse is caring for a 17-year-old male client with Duchenne muscular dystrophy. When assisting the client during a hospitalization for pneumonia, which anticipated nursing interventions would reflect client specific care? Select all that apply.

Assisting the client to a Fowler's position for a breathing treatment Clearing a path to the bathroom for safe and easy access Providing directions to the client's educational level

The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which of the following equipment does the nurse need to perform the injection? Select all that apply.

Medication administration record 27-gauge, ½" needle

Which of the following measures should a home healthcare nurse implement to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

During the entry phase of a home visit, the nurse is likely to perform which of the following tasks?

The nurse establishes nursing diagnoses for the client.

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind?

The nurse needs to be creative in integrating the technical and relational aspects of care.

A client on the genitourinary floor has refused all medications for 3 days. A nurse caring for this client asks why he isn't complying with his medication. The client states, "I don't want to take those pills anymore." The nurse informs the client that he must take all the medication the physician orders. With this statement, the nurse has violated the:

client's right to refuse medication.

A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal of nursing care at this time is to:

prevent feelings of isolation

A nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates a good understanding of an advance directive?

"A living will allows my decisions for health care to be known if I can't speak for myself."

A client with physical deficits related to a recent cerebral vascular accident states with tears in her eyes, "I no longer can take care of myself." Which statement by the nurse is most therapeutic?

"It is hard not be able to care for yourself."

A young woman will receive 6 months of chemotherapy for cervical cancer. She is a single parent of two young children and can no longer work. The nurse contacts a social worker to help plan continuing care. The client states, "I feel overwhelmed. How can the social worker help me?" Which responses by the nurse about the role of the social worker are appropriate? Select all that apply. You Selected:

"The social worker is a part of a multidisciplinary team that helps plan care for clients with cancer." "The social worker can assist in locating resources and programs to assist you during your treatment." "Based on your financial situation and need to care for your children, the social worker can help you identify needed resources at this time." "Your entire family will be included in the treatment plan. Your needs and those of your children will be assessed and determined so that referrals can be made to appropriate resources."

A nurse is administering medications to a client diagnosed with hepatitis B. When the nurse hands the client his/her medications, the client says, "I would rather not take that pill or any others. I know there is no cure for hepatitis B." The nurse recognizes that the client is expressing feelings of hopelessness about the diagnosis. Select the best responses by the nurse. Select all that apply.

"You can lead a long and fairly healthy life if you are compliant with your medications." "You seem frustrated. Would you like to talk?" "You have the right to refuse any medications. Would you like to discuss your feelings about this disease?"

There has been an increase in medication errors and errors in prescribing laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which situations? Select all that apply.

1. when a medication prescription or critical laboratory result is received verbally or over the telephone 2. when any verbal or phone prescription is received

The nurse-manager of a home health facility includes which item in the capital budget?

A $1,200 computer upgrade

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

A graphic sheet.

Which of the following is the clearest example of a nurse applying the principles of community-based care?

A nurse provides wound care for a client's venous ulcer at an ambulatory clinic near the client's

Which of the following circumstances likely requires the most documentation and communication by the nurse?

An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia.

Which method would the nurse use to identify the educational needs of clients in a senior center?

Conduct focus group interviews and have the clients fill out a survey.

When developing a care plan for a client with a do-not-resuscitate (DNR) order whose death is imminent, which of the following types of care should the nurse provide? Select all that apply.

Food and fluids, as tolerated Analgesics, as ordered Access to spiritual care providers upon the client's request

In developing a plan of care for a client who has had previous episodes of angry verbal outbursts, the nurse plans to take an educational approach to the problem. Arrange the following steps the nurse should take from first to last. All options must be used.

Help the client identify triggers for his anger. Assist the client to recognize the early cues that he is angry. Identify alternate ways to express his anger. Practice with the client appropriate ways to express his anger.

A nurse implements a health care facility's disaster plan. Which action should she perform first?

Identify a command center at which activities are coordinated.

A nurse who works on a psychiatric unit arrives to work disheveled, unkempt in appearance, and smelling of alcohol. What is the best approach for the nurse's colleague on the night shift to manage this situation?

Immediately report the concern to the appropriate leader or manager in charge.

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply.

Monitor distal pulses of the affected extremity Maintain the leg elevated above the level of the heart. Administer anticoagulation per healthcare provider's orde

Which moral principle is a nurse applying when she decides what is best for a client and acting without consulting the individual?

Paternalism

P I E

Plan Intervention Evaluation

Which client outcome best indicates effective mental health care coordination when the nurse uses a client-centered approach?

Preferred client outcomes vary from client to client.

After the physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond?

Provide the information requested.

A client is experiencing alcohol withdrawal. He wakes up and screams, "There is something crawling under my skin. Help me." What should the nurse do in order of priority from first to last? All options must be used.

Remind the client that he is having withdrawal symptoms and that these will be treated. Take the client's vital signs. Assess the client for other withdrawal symptoms. Administer a dose of lorazepam depending on the severity of the withdrawal symptoms. Chart the details of the episode in the medical record.

he nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners?

Respiratory Therapist

A health care facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietitian, and nurse involved in the client's care are required to collate all information for easy access. Which style do you think the agency is following to record the client details?

SOAP charting.

A client is brought to the mental health center by a police officer for an evaluation because she has been bothering other people when she eats in the hotel restaurant. She denies this, will not give her name, and holds tightly to her purse. She refuses to talk to anyone except to say, "You have no right to keep me here. I have money, and I can take care of myself." Which factor would be most relevant to a decision about this client's disposition?

She seems able to care for herself.

The nurse walks into the room of a client who has a "do not resuscitate" prescription and finds the client without a pulse, respirations, or blood pressure. What should the nurse do first?

Stay in the room, and call the nursing team for assistance.

A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS)/nursing care delivery model (NCDM) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS/NCDM?

Team Nursing

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

To investigate the quality of care in the agency.

A nurse is completing a home visit to an older adult receiving regular dressing changes for treatment of a venous ulcer. As a provider of home healthcare, the nurse recognizes that the primary goal of this practice is:

To maximize the independence and health of clients.

A client with borderline personality disorder becomes angry when he is told that his psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse is most helpful in dealing with the client's anger?

You had to wait. Can we talk about how this is making you feel right now?"

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:

autonomy.

Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next:

discuss the situation and possible courses of action with the dietitian and the client.

Justice

fair treatment in matters related to physical and psychosocial care and use of resources

The development of disaster plans should take into consideration that children are more susceptible to the effects of a chemical attack than adults because children:

have thinner skin than adults.

It is important for nurses to communicate with clients about their health care because

health care services are often specialized and fragmented.

The nurse is developing a primary disease prevention program for older adults. Which topic is the most appropriate?

immunizations for influenza

A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should:

initiate a time-out.

A nurse fails to give the evening dose of an IV antibiotic that is to be administered every 12 hours. The evening dose was scheduled for 1800; it is now 2200. The nurse should next:

report the incident to the health care provider.

The hospital is responding to a mass casualty disaster with adult and pediatric victims. After reallocating staff, the charge nurse on the pediatric floor should:

review the census for clients that are candidates for early discharge.

An 18-year-old pregnant woman tells the nurse that she is concerned that she may not be able to take care of herself during her pregnancy. She states that she is not sure what prenatal care is available, or if she should access it. The nurse should recognize that the client:

should be referred to community resources available for pregnant women.

A client is being discharged from the acute inpatient unit but needs further continuous supervision that is less intense than inpatient hospitalization. The nurse should refer the client to which setting?

subacute unit

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.

to ensure efficient and accurate communication to prevent medication errors to ensure client safety

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing end-stage Kaposi's sarcoma. Concerned that the health care team is investing too much energy in keeping him alive, he asks that they not attempt any more interventions. How should a nurse respond to this client?

"We have to make sure you've signed an advance directive."

The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns?

"Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself."

A nurse is assigned to assist with the admission of a laboring client. Which of the following actions are appropriate? Select all that apply.

1. Asking about the estimated date of childbirth. 2. Taking maternal and fetal vital signs. 3. Asking about the amount of time between contractions.

A nurse is working within the managed care delivery model. Which of the following is true regarding managed care?

All systems reflect the values of efficiency and effectiveness.

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication?

Checklists.

A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing?

Caring for the same child from admission to discharge

Which infections require contact precautions? Select all that apply:

Clostridium difficile Methicillin-resistant staphylococcus aureus

The nurse is preparing to begin discharge planning with a client whose pulmonary embolism has recently resolved. Which of the following factors should the nurse prioritize during this process?

The client's identified needs and goals.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order.

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day?

complete regular admission procedures.

A home health nurse is providing care to a palliative care client with liver cancer. Which classifications of medications are anticipated on the medication administration record? Select all that apply.

Narcotics Stool softeners Antiemetic

A nurse preparing to administer medications to a client admitted to a respiratory unit is using the computerized medication-dispensing system and finds that the password is not working. The nurse should do which of the following? Select all that apply.

Ask computer support to reset the password. Secure the medication until the problem can be corrected.

Which option is an example of a primary preventive measure?

Avoiding overexposure to the sun

A client with ascites is experiencing severe respiratory distress and refuses endotracheal intubation. What should be the nurse's first action?

Determine whether the client is competent to make the decision.

A nurse who provides care on a post-surgical unit is performing discharge teaching as a component of her effort to ensure continuity of care. Which of the following is the primary goal of continuity of care?

Ensuring a smooth and safe transition between different healthcare settings.

A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of her car and beginning to approach the client's building, a group of men begin following and jeering at her. Which of the following is the nurse's best response to this situation?

Leave the area in her car, provided she can get to it safely.

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as:

Moxifloxacin 400 mg daily.

The nurse transcribes the following physician's order onto the client's medication record: September 15, 2012 Administer 10 gtt of timolol maleate ophthalmic solution AU daily. John Bloom, MD Which components of the medication order should the nurse question? Select all that apply:

Number of drops Route

A client with metastatic bone cancer has signed a Do Not Resuscitate (DNR) order specifying comfort care only. Which would be included in the client's plan of care? Select all that apply.

Suctioning thick secretions to relieve dyspnea Administering oral pain medication every hour

Which facility would the nurse rank as the lowest priority to expand when developing a community-based service program for clients with chronic mental illnesses?

long-term hospitals

When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, she realizes the client doesn't fully understand the surgery. She approaches the physician, who curtly says, "I've told him all about it. Just get the consent." The nurse should:

tell the physician the client isn't comfortable consenting to surgery at this point.

The nurse is a member of a team that is planning a client-centered, community-based approach to care of clients with chronic obstructive pulmonary disease (COPD). In which areas should the team focus on improving quality of care and delivery? Select all that apply.

the community clinical information systems delivery system design

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff?

Logging off a computer containing client information

In preparing for a client's admission to the unit, what is the nurse's responsibility?

Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff.

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

Charting by exception.

The nursing is caring for a newly admitted client with diabetes insipidus. When forming the plan of care, which nursing diagnoses are anticipated? Select all that apply.

Anxiety Activity intolerance

During a unit meeting attended by clients and staff, several clients are criticizing their primary nurses. These clients have also been intimidating two other clients who have recently been admitted to the unit, and now the new clients have stopped sharing their opinions during the meeting. What is the first action for the nurse to take?

Ask the clients criticizing their nurses to suggest some possible solutions for the practices they are criticizing.

A nurse is assigning tasks to the unlicensed assistive personnel and the practical nurse on the client care team. Which of the following tasks will the nurse plan to perform personally? Select all that apply.

Assessing a client who just returned from cardiac catheterization Taking the health history of a newly admitted client

the nurse is caring for a client on hemodialysis who has an arteriovenous (AV) fistula in the right arm. When managing a client's plan of care, which instructions would the nurse determine as a priority is being completed? Select all that apply.

Avoiding all blood pressure readings and trauma to the right arm Assessing the shunt by auscultating a bruit Completing arm and finger exercises

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport.

A nurse is working on an oncology unit that uses a computerized medication access system to minimize medication errors. What steps are needed to verify the client's identity before administering the medication? Select all that apply.

Scanning the client's identification bracelet with the computer system's barcode reader Asking the client to state his/her name and date of birth Comparing the identification bracelet to the medication administration record

When creating a therapeutic environment for a client, the nurse should encourage which of the following during the rehabilitative phase in the acute care setting? Select all that apply.

Short family visits in the room Referrals for discharge planning

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment?

Speech therapist.

The nurse is transferring a child who has had open heart surgery from the intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. The nurse from the pediatric intensive care unit should include which information in the report to the nurse on the pediatric unit? Select all that apply.

medications being used current vital signs potential for blood pressure to drop drip rate for the intravenous infusion time of the most recent dose of pain medication

A client's breathing stops after receiving the wrong medication. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next? Select all that apply.

Do not document in the nursing notes about an incident report being completed. Notify the nursing supervisor and or medical director. Prepare for remediation on medication administration.

A client, diagnosed with Alzheimer's disease, is a new resident in a long-term care facility. The client has difficulty finding his/her room and is seen wandering into the room of others. When discussing the situation at a multidisciplinary conference, which client centered actions would the nurse suggest? Select all that apply.

Ensure that the client has prescribed hearing aids and glasses on throughout the day. Place a box with familiar personal items outside the client's door for visual recognition. Assign the client to a room close to the nursing station for closer monitoring. Provide verbal cueing as to where the client's room is located.

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply.

1. triage priority 2. identifying information when possible (such as name, age, and address) 3. medications and treatments administered

The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. The nurse should next:

explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.