E/L

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

4 Observing care provided to the client without the client's permission

The registered nurse (RN) is educating a new RN on the "law and order orientation" found in level 2 of Kohlberg's theory of moral development. Which statement by the new RN indicates that the teaching has been effective?

1 "An example of this is: If I skip down the hall, will the teacher be mad at me?"

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? Carol is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

1 "I cannot discuss any client situation with you."

The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate would indicate to the nurse that there is a need for further teaching?

1 "I don't think you need to do that."

The nurse is working at a computer in the nurses' station when the charge nurse from another nursing unit approaches and asks about the condition of the client in room 432, stating, "The client is my neighbor, and I want to check on them." The nurse would make which most appropriate response?

1 "I'm sorry, I cannot tell you."

Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? Select all that apply.

1 "This document is a separate document from my final will." 4 "This document describes the kind of treatment I want depending on how sick I am."

A client has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has been losing weight for 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins to cry and tries to eat more. Based on the nurse's actions, the nurse may be accused of which legal tort?

1 Assault

A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation?

1 Assault

The nurse calls a client's primary health care provider (PHCP) to report that the client, who has heart failure, is demonstrating increased wheezes on lung auscultation and dyspnea. The PHCP is in a hurry because of involvement in a critical care situation in the hospital emergency department and gives the nurse a telephone prescription for furosemide. Afterward, the nurse realizes that the route of the medication is unclear. Which action by the nurse is the most appropriate?

1 Call the PHCP who gave the telephone prescription and clarify the prescription.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action would the nurse take initially?

1 Contact the client's primary health care provider.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take?

1 Contact the nursing supervisor.

The nurse manager is planning to implement a change in the nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance during the change process. Which primary technique would the nurse use in implementing this change?

1 Introduce the change gradually.

The nurse is acting in the role of client advocate in which situations? Select all that apply.

1 Promoting client comfort 3 Questioning primary health care provider prescriptions 4 Supporting a client decision regarding a health care choice

While eating lunch in the hospital cafeteria, a nursing student overhears two nurses talking about a client. Which is the important information for the nurses to remember when talking about the client?

1 Talking about a client in a public place is a violation of the client's confidentiality.

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

1 The Good Samaritan law will protect the nurse.

Which identifies accurate documentation notations made by the nurse? Select all that apply.

1 The client is resting in bed with the eyes closed. 2 Abdominal wound dressing is dry and intact without drainage. 5 The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Which notations indicate accurate nursing documentation by the nurse? Select all that apply.

1 The client slept through the night. 2 Abdominal wound dressing is dry and intact without drainage. 5 The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

awakened from a coma and asks for the spouse,, who was killed in the same accident. The family does not want the client to know at this time that the spouse has died. The family wants all nursing staff to tell the client that the spouse was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps would the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used.

1-6 2-3 3-5 4-4 5-1 6-2

The registered nurse (RN) is beginning a new job in a clinic and attends an orientation session. After the session, another new employee asks the RN to describe case management, a component of the discussions in the orientation session, because the employee did not clearly understand the concept. Which statement made by the nurse is the most appropriate?

2 "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care."

A client is scheduled for surgery, and the surgeon has explained the procedure and is about to obtain informed consent. Which statement by the client would indicate to the nurse that the client needs further teaching before giving informed consent to the procedure?

2 "I know my surgeon explained it, but I still don't know why surgery is needed."

A client refuses to take a medication. Which is the most therapeutic response by the nurse?

2 "You don't have to take the medication if you don't want to."

A client with left-sided weakness needs assisted living. The client's family plans to sell the client's home to pay for assisted living, but the client refuses to sell because the client feels that the family should pay the expenses. What would the nurse do at this time?

2 Ask the client to share experiences about the house.

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.

2 Battery 3 Assault 5 False imprisonment

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse would take which best action?

2 Clarify with the team leader to make a safe ICU client assignment.

After initial assessment the nurse determines the need to place a restraint on a client. The client refuses application of the restraint. What is the best nursing action for this client?

2 Contact the primary health care provider (PHCP).

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the document to correct the error. The nurse would take which actions to correct the error? Select all that apply.

2 Draw one line through the error, initialing and dating it. 6 Document the correct information and end with the nurse's signature and title

The registered nurse (RN) is observing a licensed practical nurse (LPN) who is caring for a client with a uterine tumor who had a vaginal hysterectomy. The RN would intervene if the RN notes the LPN performing which action?

2 Elevating the knee gatch on the client's bed

A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action?

2 Massaging the injection site after injection

The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply.

2 Monitor language and tone. 3 Adopt a "need-to-know" policy. 4Adopt a "need-to-know" policy. 6 Hold yourself and one another accountable.

The nurse is caring for a client who has just returned from having a right-sided renal biopsy. Which action by the assistive personnel (AP) requires immediate follow-up by the nurse?

2 Positioning the client on the left side

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse would take which action(s) to correct the error in the MAR? Select all that apply.

2 Right-click on the entry and modify it to reflect the correct information. 3 Document the correct information and end with the nurse's signature and title. 4Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5 Document in a nurse's note in the client's record detailing the corrected information.

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse would inform the AP that making this accusation has violated which legal tort?

2 Slander

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care?

2 The informed consent needs to be obtained from the client

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse would take which priority action?

4 Obtain telephone consent from a family member witnessed by two authorized individuals.

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?

3 "Being respectful and concerned will ensure that I'm attentive to my client's rights."

The experienced nurse is observing a newly hired graduate nurse count opioids as part of the orientation process. The experienced nurse determines that the newly hired nurse needs further teaching about the procedure for counting opioids when which statement is made?

3 "If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift."

The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse would intervene if the student planned to implement which action to apply the medication?

3 Apply saline-soaked dressings over the medication.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?

3 Call the nursing supervisor and report the incident

The nurse discovers a coworker in the linen closet injecting a medication into the antecubital area. Which most appropriate action would the nurse take?

3 Call the nursing supervisor.

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

3 Call the nursing supervisor.

The nurse manager is reviewing documentation describing a client's progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The nurse manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control during the prior 48 hours. Who would the nurse manager contact next?

3 Case manager, to determine whether the predicted variance has been negotiated with the health insurer

The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Which is important information for the nurse to remember?

3 That an informed consent needs to be obtained from the client

The nurse hears a client calling out for help and finds the client lying on the floor. The nurse performs an assessment and assists the client back to bed. The primary health care provider is notified of the incident, and the nurse completes an incident (occurrence) report. What would the nurse document on the incident report?

3 The client was found lying on the floor.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider of the incident, and completes an incident report. Which statement would the nurse document on the incident report?

3 The client was found lying on the floor.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement would the nurse document on the occurrence report?

3 The client was found lying on the floor.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

3 Transport the victim to the operating room for surgery.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

3 Wearing gloves and a gown only when giving direct care to the client

An 87-year-old person is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her adult child frequently hits the client if supper is not prepared on time when arriving home from work. Which is the most appropriate nursing response?

4 "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

An older client is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that a family member frequently hits the client if supper is not prepared on time when the family member arrives home from work. The nurse plans to make which most appropriate response?

4 "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

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

4 "I will call the nursing supervisor for assistance regarding your request."

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The nurse plans to make which most appropriate response to the client?

4 "I will call the nursing supervisor to seek assistance regarding your request."

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

4 "I will call the nursing supervisor to seek assistance regarding your request."

While making rounds a client asks the nurse, "What's wrong with that person in the room next to me? I hear crying all night long." What is the nurse's best response?

4 "I'm sure it's upsetting to hear the crying, but I'm not able to discuss details about other clients."

Laptop computers have been purchased by a community hospital to be used in the nursing units for documentation. The nurse educator at the hospital plans in-service educational sessions regarding the use of the computers and the new documentation system. The nurse educator anticipates some resistance to the use of the computers and would plan to best deal with this difficulty by doing what?

4 Allowing the nurses extra time to work with the new computer system

A primary health care provider (PHCP) asks the nurse to discontinue tube feeding in a client who has a terminal condition. The PHCP tells the nurse that the request was made by the client's spouse and children. What would the nurse check for first before carrying out the prescription?

4 Authorization by the family to discontinue the treatment

The nurse employed in a surgical unit in a hospital arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is most appropriate?

4 Call the nursing supervisor to discuss the request to report to pediatrics.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

4 Confront the AP to encourage verbalization of feelings regarding the change.

A homeless client comes to the emergency department complaining of severe pain in the toes of both feet. On assessment, it is found that all of the toes are black in color and that amputation is necessary. The client refuses the surgery and insists on returning to street living. Which describes the next appropriate action to take?

4 Discuss the surgical procedure and its purpose with the client, and encourage the client to talk about concerns and feelings.

The nurse has made an error in documenting an assessment finding in the bedside flow sheet. What action would the nurse take to correct the error?

4 Draw a line through the error, initial and date the line, and then provide the correct information.

The nurse suspects that a client is not fully aware of the implications of a procedure and the client is about to sign an informed consent. What action would be most appropriate for the nurse to take?

4 Inform the PHCP that the client does not appear to fully understand the procedure and withhold obtaining the signature.

The nurse is caring for a client who has just returned from having a cystoscopy with biopsy. The nurse would intervene if an assistive personnel (AP) is observed taking which action?

4 Insisting that the client ambulate immediately after the procedure

The nurse gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the primary health care provider to report the occurrence. Which action would the nurse manager anticipate will take place next?

4 The incident report will be used to review quality of care and determine potential risks.