Accountability

A client who is legally blind must undergo a colonoscopy. The nurse is helping the physician obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step? a) Read the consent form to the client and ask him if he has any questions. b) Encourage the client to read the form. c) Document on the consent form that the client is unable to sign the consent because he is legally blind. d) Make sure the client's family is present when he signs the consent form.

A. Read the consent form to the client and ask him if he has any questions. The nurse should read the consent form to the client and make sure that he understands what was read to him. The physician and nurse should answer any questions the client has before he signs the consent form. The client's family doesn't need to be present. The legally blind client may sign the consent form.

An elderly client with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities; he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I'll blow him away with my shotgun. He has never respected my property line and I've had it!" Which of the following actions should the nurse take? a) Report the comment to the neighbor, the daughter, and the police because there is the potential for a criminal act. b) Observe the client more closely, but do not report his threat, because he will likely not be able to follow through with it because of his dementia. c) Report the comment to the neighbor, the intended victim, but refrain from telling the daughter who will just worry about actions of her father she cannot control. d) Report the comment to the client's daughter so she can observe him more closely, but refrain from telling the neighbor due to privacy regulations.

A. Report the comment to the neighbor, the daughter, and the police because there is the potential for a criminal act. The neighbor and the daughter could be harmed (if the daughter should try to stop her father from using a gun), so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so and to document it can result in civil penalties. The client's early dementia would likely not prevent him from carrying through his threat.

The physician is calling in a prescription for ampicillin for a neonate. The nurse should do which of the following? Select all that apply. a) Write down the order. b) Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse. c) Ask the physician to confirm that the order is correct. d) Repeat the order to the physician over the telephone. e) Ask the physician to come to the hospital and write the order on the chart.

A. Write down the order. C. Ask the physician to confirm that the order is correct. D. Repeat the order to the physician over the telephone. The nurse should write down the order, read the order back to the physician, and receive confirmation from the physician that the order is correct as understood by the nurse. It is not necessary for the physician to come to the hospital to write the order on the chart or to have the nursing supervisor cosign the telephone order.

A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. The nurse should suggest that the family join which organization? a) Emotions Anonymous b) Al-Anon c) Alcoholics Anonymous d) Make Today Count

B. Al-Anon Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality? a) Reading all information to the client before faxing b) Determining that the client has authorized release of the information c) Obtaining a written order from the client's primary physician to fax the information d) Making sure the client's name and date of birth are displayed on the fax cover sheet

B. Determining that the client has authorized release of the information A nurse must obtain client authorization before sending any confidential information to a nursing home or other facility. A client's name and other protected information should never appear on a fax cover sheet. It isn't necessary to read the information to the client before sending it. A physician's order doesn't give a nurse the right to send confidential information without the client's permission.

The nurse delegates the care of a multiparous client who gave vaginal birth to a viable term neonate 30 hours ago and is preparing to be discharged to a licensed practical nurse (LPN). The nurse should instruct the LPN to notify the nurse if the client exhibits which of the following? a) Excessive perspiration during the assessment. b) Pulse rate of 100 bpm. c) Frequent voiding in large amounts. d) Oral temperature of 99° F (36.8° C).

B. Pulse rate of 100 bpm During the first week postpartum, the client's pulse rate should be slow, with an average of 60 to 70 bpm. A pulse of 100 bpm warrants further investigation to rule out a possible infectious process or postpartum hemorrhage. An oral temperature of 99° F (36.8° C) is within normal limits. Excessive perspiration and frequent voiding in large amounts are caused by the normal diuresis that occurs as the body returns to its pre-pregnant state.

A nurse arriving for duty notes that a nursing assistant (or unregulated care provider [UCP]) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UCP? a) Supervise the UCP during the treatments involving sterile technique. b) Reassign the UCP to a client requiring basic tasks that the UCP has mastered. c) Provide the UCP with a list of resources to guide the implementation of care. d) Make sure the UCP has practiced sterile technique on at least one other occasion.

B. Reassign the UCP to a client requiring basic tasks that the UCP has mastered. The nurse is accountable for the delegation of tasks to UCPs. The nurse delegates tasks to UCPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UCPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UCP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UCP has the knowledge and skill to provide the care or carry out the task.

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: a) ask the charge nurse to talk with the physician. b) tell the physician he didn't give the client enough information. c) explain the procedure more fully to the client and obtain his signature. d) tell the physician the client isn't comfortable consenting to surgery at this point.

B. tell the physician the client isn't comfortable consenting to surgery at this point. The nurse has evaluated the client's knowledge concerning the surgery and determined that he doesn't have enough information to give informed consent. Even though the physician might want to move ahead, the nurse should advocate for the client by telling the physician the client isn't ready for the surgery. Telling the physician that he hasn't given the client enough information would be rude. The nurse shouldn't ask the charge nurse to talk with the physician unless the physician refuses to accept the nurse's professional opinion. Explaining surgery for the purpose of obtaining consent is beyond the nurse's scope of practice.

The night nurse has completed a change-of-shift report. The day nurse making rounds notes that a postpartum client receiving magnesium sulfate has developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below ordered. In addition to adjusting the infusion rate and notifying the primary health care provider, which of the following actions by the day nurse is most important? a) Ask the charge nurse if an incident report is necessary. b) Discuss the matter with the night nurse the next time he or she works. c) Complete an incident report. d) Evaluate the client's blood pressure for 4 hours before taking any other action.

C. Complete an incident report. Client safety is the highest priority. A nursing error has occurred, and so an incident report is required. If the day nurse decides to discuss the issue with the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered. Again, client safety is the highest priority.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse? a) Ask another nurse to irrigate the nasogastric tube for him/her each time it is required. b) Refuse the assignment because he/she has never irrigated a nasogastric tube. c) Contact the nurse educator for an in-service and support in performing the skill. d) Irrigate the nasogastric tube by following the steps outlined in the procedure manual.

C. Contact the nurse educator for an in-service and support in performing the skill. The nurse has a responsibility for recognizing his/her limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide inservice and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in his/her learning or expertise.

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? a) Complete an incident report. b) Notify the unit manager. c) Discuss the breach of practice with the physician. d) Ask the nurse educator to in-service the physician.

C. Discuss the breach of practice with the physician The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step.

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action? a) Place the incident report on the chart. b) Call the family to inform them. c) Give the incident report to the nurse-manager. d) Omit mentioning the fall in the chart documentation.

C. Give the incident report to the nurse-manager. The incident report should be given to the nurse-manager. Incident reports are processed independently of the client's chart, and do not become part of the health record. It is appropriate, ethical, and legally required that the fall be documented in the chart. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse-manager or the physician should place the call.

A nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. After attempting to reorient the client, the client remains unable to demonstrate appropriate use of the call light. To maintain client safety, the nurse should first: a) Administer a sedative. b) Contact the physician and request an order for soft wrist restraints. c) Increase the frequency of client observation. d) Ask family members to stay with the client.

C. Increase the frequency of client observation The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible, delegating to the nursing assistant to check on the client more frequently, or both. If family members can stay with the client, that is an option but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually exacerbate the problem.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation? a) Report the incidents to the facility's lawyer. b) Pass the information on to the doctor and the next shift staff. c) Notify the supervisor and call the police. d) Remind the residents and family members not to leave valuables unattended.

C. Notify the supervisor and call the police. The supervisor should be made aware of the situation and the police should be called to investigate the potential theft. The other answers do not advocate for the clients and their families. It is the responsibility of the nurse to take action because the nurse was the person to receive the information. This is known as due diligence.

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment? a) Ask the aunt if she would like the nurse to take care of her while in the hospital. b) Notify the supervisor that this is a relative but the relationship will not be a conflict. c) Notify the supervisor and provide care until another nurse can be assigned to the client. d) Accept the assignment and not disclose the relationship with the client.

C. Notify the supervisor and provide care until another nurse can be assigned to the client. The nurse should notify the supervisor of the relationship with the client and ask to be reassigned. If no other nurse is immediately available, the nurse should provide the necessary care until another nurse can assume responsibility for the aunt's care. The other answers are incorrect because the nurse may not be able to ensure that the therapeutic nurse-client relationship can be maintained when caring for a family member.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions? a) Have the LPN take the vital signs again, phone the operating room, and cancel the surgery. b) Sign off the chart but flag that vital signs are abnormal; allow the client to go down to the operating room. c) Take the vital signs, and in the future do not delegate this preoperative responsibility. d) Notify the surgeon and await his/her decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.

D. Notify the surgeon and await his/her decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs The purpose of a registered nurse's signing off the chart is to ensure that the safety of the client has been assessed. Abnormal vital signs identify that priority systems indicate that a stressor or infection is present.

A client on the mental health unit is granted a weekend pass. The physician writes an order for the nurse to provide the client with enough medication to cover the weekend. What would be the most appropriate action by the nurse? a) Refuse to comply with this order because it is considered "dispensing." b) Ask the physician to prepare the weekend medication for the client. c) Send the order to the pharmacy for processing of weekend medications only. d) Prepare labeled containers with medication taken from the client's existing medications.

D. Prepare labeled containers with medication taken from the client's existing medications Taking a medication from an existing medication container that has already been dispensed to the client by a pharmacist is referred to as "repackaging" and falls within the scope of practice of the nurse. The container should be clearly labeled with the client's name, the name of the drug, and instructions for taking the medication. The other options are not correct because they do not fall within the scope of practice for the nurse and the steps are unnecessary. Refusing would prevent the client from having medication on the weekend pass.

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. The nurse should: a) Delay feeding the client for 1 hour and then recheck the residual. b) Dispose of the residual and continue with the feeding. c) Withhold the tube feeding and notify the physician. d) Readminister the residual to the client and continue with the feeding.

D. Readminister the residual to the client and continue with the feeding Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the physician and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses.

A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse? a) Give the placebo as ordered by the physician. b) Consult with the pharmacist to discuss the dosage of the placebo. c) Give the placebo but do not tell the client it is a stronger medication. d) Refuse to administer the placebo to the client.

D. Refuse to administer the placebo to the client. The nurse should refuse to give the placebo and should also refuse to misinform the client. The nurse has a responsibility to explain the client's medications to the client. The client can then make an informed decision about accepting or refusing the medication. The other options are incorrect because the nurse would be misinforming the client about the medication that is being administered. The client would not be able to provide informed consent.