exam 1

A nurse posts the following to their social media account; "Today was a bad day at work; my patients were tough to work with, especially one in particular". What response by the nurse manager is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea (shortness of breath). The nurse telephones the health care provider and provides an SBAR report. Which statement represents the second step in this type of communication?

"This client has a medical history of heart failure."

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse?

"I know this is hard for you. Is there any way I can help?"

The health care provider is yelling at the nurse in the patient's room because the patient has not received an intravenous antibiotic. Which statement by the nurse demonstrates appropriate assertiveness?

"Let's go to the nurses' station, and I will explain."

A client is questioning the need for surgery. The client asks the nurse, "What should I do?" Which answer by the nurse is based on advocacy?

"Tell me why you do not want the surgery."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

The nurse has inadvertently administered medication ordered for Client A to Client B. What is the appropriate nursing action? Select all that apply.

-Complete an incident report. -Contact the provider to report the error -Assess Client B thoroughly.

The nurse suspects that another staff member may have a substance use disorder. What changes would the nurse observe that would indicate possible substance use? Select all that apply.

-Confusion about clients' plans of care -Clients frequently reporting ineffective pain relief following administration of opioids -A decrease in personal hygiene and appearance

The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document?

A living will

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the:

Code of Ethics for Nurses

A nurse provides client care within a philosophy of ethical decision-making and professional expectations. What is the nurse using as a framework for practice?

Code of Ethics for Nursing

When signing a form as a witness, your signature shows that the client:

Has signed that form and the witness saw it being done

A diabetic client discovers that the client's name is published in a research report on diabetic care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed?

Invasion of privacy

A confused client who fell out of bed because side rails were not used is an example of which type of liability?

Negligence

A nurse knows that the expression "Do not cause harm" refers to which ethical principle?

Nonmaleficence

You are a nurse in an ER. Your elderly client appears withdrawn around his daughter and has questionable bruises. What action should the nurse take?

Notify the nursing supervisor for further guidance.

Most litigation in the hospital comes from the:

Nurse following an order that is incomplete or incorrect

What is an example of the doctrine of double effect?

Nurse gives ordered high dose of morphine to dying patient.

Which situation is an example of battery that the nurse may witness while performing duties at the health care facility?

Performing a surgical procedure without getting consent

Even though the nurse may obtain the clients signature on a form, obtaining informed consent is the responsibility of the:

Physician

A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next?

Question the order for the medication.

The scope of Nursing practice is legally defined by:

State nurses practice acts

A nurse is providing patient care in a hospital setting. Who has responsibility and accountability for the nurse's actions?

The nurse

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse ensures that the client's family signs the consent form.

A client nearing the end of life requests that the client be given no food or fluids. The physician orders the insertion of a feeding tube to feed the client. What is the primary concern of the nurse providing care?

The nurse faces an ethical dilemma about inconsistent courses of action.

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

Therapeutic communication

Which ethical principle is related to the idea of nursing students controlling their life and outcome of nursing school?

autonomy

The nurse is educating a client regarding use of the incentive spirometer. When evaluating the client's knowledge about the incentive spirometer, which best represents that the client has learned correct use of this device?

The client organizes materials needed and gives return demonstration

Which actions should the nurse take to ensure that client information remains confidential? Select all that apply.

-Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. -Exit the client's room when called on the hospital-issued cell phone about another client on the team. -Verify the number in the fax machine as correct prior to transmission.

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply.

-Identify the day and time for each entry -Document in chronological order -Sign every entry -Acknowledge the client's response to the medication

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

-Obscuring identifiable names of clients and private information about clients on clipboards -Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public -Keeping record of people who have access to clients' records

The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply.

-The client has a clean and dry abdominal dressing. -Pain level is currently a 2 following administration of intravenous morphine. -Ms. J-Lo is in Room 7, admitted postoperatively for an open appendectomy. -No new labs have been ordered after surgery.

You have four clients with discharge orders. Which client below would you want to suggest homecare for?

A 40 year old diabetic who needs assistance getting to the restroom.

An illegal immigrant with no health insurance sustained life-threatening injuries in an automobile accident. Which action in this case demonstrates the ethical principle of justice?

Airlifting the client to a local trauma center for emergency surgery

To practice ethically, the nurse should avoid:

Allowing the nurse's own judgment to guide practice.

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing?

Assault

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

Assess for cultural differences.

A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee?

Assist in decision making based on the client's best interests.

Which one of the following is the nurse's best legal safeguard?

Competent, safe practice

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan?

Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique.

A client is brought to the emergency department by an adult child, who states, "I am unable to care for my parent anymore. Although I would like to, financially and physically I can't do it anymore." What ethical problem is the adult child experiencing?

Distress

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?

Document the client's claims and the events surrounding the alleged incident.

A nurse forgot to document that a client drank 120ml of water at 0830. It is now 1030. What action should the nurse take?

Document the water for the 0830 time

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request?

Identify and recommend some credible websites appropriate to the spouse's learning needs.

When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed?

Invasion of privacy

What is the primary ethical dilemma posed when using restraints on an older adult client in a long-term care setting who is confused?

It threatens autonomy.

The nursing is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

The patient is in severe pain and asks for pain medicine. The family refuses all pain medicine because they are afraid the medicine might end the patient's life. Where could the nurse obtain guidance in this situation?

Review the literature about providing pain relief with the family.

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?

Speak directly to the client

You notice another nurse on the floor not wearing gloves when helping a client use the restroom. How do you react?

You should let the nurse know they must use gloves and wash their hands before and after patient care.