NU370 Week 4 PrepU: Accountability

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind? Area for insulin injection Technique for injecting Accuracy of the dosage Duration of the insulin

Accuracy of the dosage o The measurement of insulin is most important and must be accurate because clients may be sensitive to minute dose changes. The duration, area, and technique for injecting should also to be noted.

The health care provider has given and signed an order for a specific client for zolpidem, 10 mg by mouth once daily at hour of sleep, and recorded the specific date and time of the order. What is the appropriate nursing action? Administer the drug. Cosign the order. Call the health care provider for order clarification. Show the order to the nurse manager.

Administer the drug. o All seven components of the order are present; the nurse can safely administer the medication. The nurse does not cosign the order, nor does the nurse need to call the health care provider for clarification or show the order to the nurse manager.

The nurse knows the written instructions for healthcare when a person is incapacitated is called Informed consent Living will Advance directive Durable Power of Attorney

Advance directive o Advance care directives are written instructions for health care when individuals are incapacitated. For people who are gravely disabled ; are found to be incompetent; cannot provide food, clothing, and shelter for themselves even when resources exist; and cannot act in their own best interests may require advance care directives and/or may require appointment of a conservator or legal guardian.

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? Care plan and client's record Critical pathway and care plan Client's record and occurrence report Occurrence report and critical pathway

Client's record and occurrence report o An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

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? Irrigate the nasogastric tube by following the steps outlined in the procedure manual. Contact the nurse educator for an in-service and support in performing the skill. Refuse the assignment because of a lack of experience in irrigating a nasogastric tube. Ask another nurse to irrigate the nasogastric tube each time it is required.

Contact the nurse educator for an in-service and support in performing the skill. o The nurse has a responsibility to recognize 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 in-service 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 learning or expertise.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take? Rewrite the entry on the correct health record indicating who made the error. Strike through the entry ensuring the original entry is still visible. Report to the nurse manager that the nurse needs guidance on documentation. Contact the previous nurse requesting that the nurse correct the error.

Contact the previous nurse requesting that the nurse correct the error. o The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.

Which would be an appropriate intervention for a child diagnosed with conduct disorder? Allow self-monitoring of the child's own behavior Avoid limiting setting to decrease confrontation Allow the child increased control over situations Have the child accept responsibility for individual behavior

Have the child accept responsibility for individual behavior o The child diagnosed with conduct disorder needs to accept responsibility for his or her own actions. The nurse must protect others from the manipulative or aggressive behaviors with these clients.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? Add the new order to the medication administration record. Inform the health care provider that a written order is needed. Call the pharmacy to have the order entered in the electronic record. Write the order in the client's record.

Inform the health care provider that a written order is needed. o Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP? Soothing the client during the procedure Initiating intravenous therapy Gathering equipment needed for intravenous therapy Securing the client on a papoose board

Initiating intravenous therapy o When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of that condition, and the potential for harm. Initiating intravenous therapy is reserved for the RN due to the potential for harm and the scope of the UAP. The UAP can assist the nurse by obtaining equipment, securing the client, and soothing the client.

Which teaching statement best exemplifies cultural competence in relation to time for the American culture? It is a sign of respect to be late for your health care appointments. It is important to be on time for your health care appointment. It is important to be future-oriented when considering your appointment time. It is important to arrive within 20 minutes of your scheduled appointment time.

It is important to be on time for your health care appointment. o In the United States, being on time and completing a job promptly are the expectation. This expectation is not the same in all cultures. It should be included when explaining cultural practice that timeliness is important. Being late for an appointment is considered disrespectful in the American culture.

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? Report the client's inability to learn to the case manager. Teach the content again utilizing the same method. Reassess the appropriateness of the method of instruction. Revise the plan to include the inclusion of a support group.

Reassess the appropriateness of the method of instruction. o It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response? Administer the medications. Ask another staff nurse to give the medications. State, "I cannot give medications for other nurses." Hold the medications for Nurse A.

State, "I cannot give medications for other nurses."

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action? Allow the new nurse to continue with the insertion and discuss the error later away from the client. Report the new nurse's error to the nurse manager for corrective action. Assign the new nurse to view videos on sterile catheter insertion. Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. o The most important priority is to ensure the client's safety. Because the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Because the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.

The nurse is administering a PRN pain medication to a child. What is the highest priority for the nurse in this situation? The nurse asks the child to explain the pain the child is having. The nurse double-checks the medication calculation with another nurse. The nurse checks the last time the medication was given. The nurse documents the effect of the medication within 1 hour of administration.

The nurse checks the last time the medication was given. o When giving a PRN medication, always check the last time it was given and clarify how much has been given during the past 24 hours. The other choices are important but checking when and how much the child has had are the priorities.

Which actions should the nurse take when applying transdermal patches? Select all that apply. assessing for skin irritation at the application site marking the patch with date and time of administration documenting in the client's record where the patch is located reusing the patch on alternate days placing the patch in the same location

assessing for skin irritation at the application site marking the patch with date and time of administration documenting in the client's record where the patch is located o The nurse should be sure to assess for any skin irritation prior to applying the patch and again after removing it. Marking the patch with date and time of administration and documenting in the client's record where the patch is located are correct, as these promote continuity of care. Reusing the patch on alternate days is incorrect, because this could reduce the therapeutic level of the drug. Placing the patch in the same location is incorrect, as this could cause irritation of the skin.

The client was admitted to the hospital with the diagnosis of iron overload. Over time, an excess of iron can damage the liver and cause heart problems. Which medication does the nurse anticipate the healthcare provider to order? ramipril montelukast deferoxamine flurazepam

deferoxamine o Deferoxamine is used for the treatment of iron overload by ridding the body of the extra iron. Montelukast is a bronchodilator used for chronic asthma. Ramipril is a antihypertensive used to treat hypertension. Flurazepam is a sedative/hypnotic that is used for insomnia.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? making a copy of the incident report for the client notifying the health care provider of the incident and the client's condition submitting the incident report to the appropriate hospital administrator documenting the incident factually in the client's record

making a copy of the incident report for the client o A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds? one that is the nurse's personal stethoscope one that the client has personally purchased for use one that remains directly outside the client's room one that remains in the client's room

one that remains in the client's room o A dedicated stethoscope and blood pressure cuff should remain in the client's room. The other answers are incorrect.

The client's blood sugar is 210 mg/dL (11.7 mmol/L) this morning. The nurse verifies a dose of 8 units of regular insulin from the sliding scale. Which sites are acceptable for the nurse to administer the insulin? Select all that apply. upper outer thighs deltoids abdomen inside forearms upper outer arms

upper outer thighs abdomen upper outer arms o For a subcutaneous injection of insulin, the nurse should pick from these areas with adipose tissue beneath the skin: upper outer thighs, upper outer arms, abdomen, or buttocks. The deltoids are an intramuscular area, and the inside forearm lacks a fatty pad beneath the skin.

A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which data would be considered subjective data? "Client's respiratory rate was 8 and labored." "Client seems very nauseated." "Promethazine 25 mg IM is administered." "Client vomited 250 mL of yellow liquid."

"Client seems very nauseated." o This statement is subjective because it is the nurse's interpretation. The other options are incorrect because they reflect objective data.

When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history? "Have you had alcohol at parties before?" "Have you smoked crack before?" "Have you smoked cigarettes?" "Have you heard that some teens like to smoke? Have you tried this?"

"Have you heard that some teens like to smoke? Have you tried this?" o When obtaining a health history from teens, the nurse should approach questions about sensitive subjects in a nonthreatening manner. This method may encourage the teen to not be afraid to ask questions and be more open. The other choices are all direct questions that may make the teen apprehensive or discourage him or her from being truthful when answering.

The nurse manger is discussing self- awareness during a staff meeting. Which statement(s) by the staff nurse best depicts self-awareness? Select all that apply. "Yes, I'll work again this evening; I don't need any more than four hours of sleep." "Yes, I can help with the nurse retention committee, but I don't know when I'll find the time." "I'm tired and hungry. I need to take a break and get something to eat." "I worry about interrupting the doctor's sleep when I call him at home." "I asked to be transferred because the nurses on this unit are critical and make me feel inadequate when I work with them."

"I'm tired and hungry. I need to take a break and get something to eat." "I asked to be transferred because the nurses on this unit are critical and make me feel inadequate when I work with them." o Self-awareness is the process of understanding one's own beliefs, thoughts, motivations, biases and limitations. A well-defined sense of self-awareness can only come after nurses carry out self-examination. Stating, "Yes, I'll work again this evening," "I don't need any more than four hours of sleep," "I worry about interrupting the doctor's sleep when I call him at home" or "Yes, I can help with the nurse retention committee, but I don't know when I'll find the time" are not depicting self-awareness.

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met? Proximate cause Damages Breach of duty Duty

Breach of duty o Failing to communicate a change in the client's condition reflects a breach of duty. Duty describes the relationship between the person and the person being sued. Nurses have a duty to care for their clients. The existence of a duty is rarely an issue in a malpractice suit. The action or lack of action must be proven as the cause of the injury. Damages refer to the injury sustained by the client.

The nurse is preparing to administer a PO medication to a 6-year-old in the hospital for an exacerbation of asthma. The nurse notes that the child is due for an oral dose of lansoprazole in 1 hour. What is the most important action for the nurse to take before administering this medication to the client? Obtain parental permission to administer this medication. Ask the mother how she usually gives this medication to the client. Clarify the order, since there is no apparent link between the client's diagnosis and the medication. Prepare to give the medication as ordered in 30 to 90 minutes.

Clarify the order, since there is no apparent link between the client's diagnosis and the medication. o There is no clear link between this client's diagnosis and the lansoprazole administration. The nurse should clarify a medication order that does not have a clear link to the client's diagnosis before giving the medication. Asking the mother how she usually gives the medication is a good idea; however, it is not the priority nursing action in this scenario. Parental permission is not required to administer this medication. Consent to treat is signed upon admission to the hospital.

Students are comparing and contrasting the roles and functions of nurse practitioners and clinical nurse specialists. The students demonstrate understanding of these roles when they identify which of the following as associated with nurse practitioners? Select all that apply. Collaboration with other disciplines Prescribing of medications Direct care provision Counseling of patients and families Consultation with nursing staff

Collaboration with other disciplines Prescribing of medications Direct care provision o Nurse practitioners define their role in terms of direct provision of a broad range of health care services to patients and their families. The focus is on providing direct health care to patients and collaborating with other health professionals. In most states, nurse practitioners have prescriptive authority. Clinical nurse specialists often focus on their education and consultation roles, which involve education and counseling of patients and families as well as education, counseling, and consultation with nursing staff.

When functioning in the practitioner role, with which of the following would the nurse be involved? Select all that apply. Helping patients navigate through the complex health system Coordinating with other disciplines Providing direct care Educating the patient and family Implementing timely investigations of problems

Coordinating with other disciplines Providing direct care Educating the patient and family o In the practitioner role, the nurse helps patients meet their needs by using direct interventions, teaching patients and family members to perform care, and coordinating and collaborating with other disciplines to provide needed services. The researcher role involves implementing timely investigations of problems. A specialized role, the clinical nurse leader, helps patients navigate through complex health systems.

A 73-year-old man has been the primary caregiver for his wife, who has multiple sclerosis (MS). After 30 years with the disease she died and he has become increasingly withdrawn and refuses to leave the house. Which nursing diagnosis is most appropriate? Low self-esteem related to feeling unloved now that his spouse has passed away Disturbed body image related to death of spouse and loss of the role of caregiver Disturbed personal identity related to the unresolved crisis of his wife's death Risk for altered self-esteem related to the recent death of his spouse

Disturbed personal identity related to the unresolved crisis of his wife's death o The client is experiencing disturbed personal identity as he is no longer a spouse or a caregiver. This is related to the recent death of his chronically ill spouse. Without her to care for he is unable to define who he is or what his role is without her. He does not have low self-esteem or disturbed body image.

Which fact should the nurse keep in mind when obtaining consent forms from clients scheduled to undergo surgery? In emergency situations, the doctor may obtain consent over the telephone. The form that is signed is not a legal document and would not hold up in court. The responsibility for securing informed consent from the client lies with the nurse. A consent form is legal, even if the client is confused or sedated.

In emergency situations, the doctor may obtain consent over the telephone. o Informed consent is the client's voluntary agreement to undergo a particular procedure or treatment, and it protects the client, the physician, and the health care institution. In an emergency situation the physician can obtain consent from the next of kin, legal guardian, or power of attorney. Consent forms cannot be obtained from confused or sedated clients. The responsibility for securing a consent form lies with the physician; the nurse may witness the client signing a consent form.

The nurse and unlicensed assistive personnel (UAP) are working together to admit a client newly diagnosed with diabetes to a nursing unit. Which task would be inappropriate to delegate to the UAP? Performing a fingerstick blood glucose test Measuring blood pressure Monitoring insulin requirements Offering sugar-free popsicles

Monitoring insulin requirements o When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of the condition, and the potential for harm. The nurse should monitor the client's need for insulin. The UAP can monitor blood pressure, offer nourishment, and perform a fingerstick blood glucose test. The UAP should report the result of the fingerstick blood glucose test to the nurse, and the nurse should determine the need for insulin based on physician orders.

Which statement about laws governing the distribution of controlled substances is true? The nurse is only at risk if diverting medication from the client; a nurse using the nurse's own personal drugs is not at risk. Nurses are responsible for adhering to specific documentation about controlled substances. When a nurse misuses controlled substances in the workplace and gets help, the nurse will not be charged with a criminal act. Substance use is not treatable.

Nurses are responsible for adhering to specific documentation about controlled substances. o Nurses have specific responsibilities regarding controlled substances, including specific documentation. Violation of controlled substances laws at the workplace is serious and a criminal act. Substance use is treatable, and the objective is to detect and treat the problem early. It does not matter where the nurse obtains the drugs; the nurse is still liable for personal actions.

A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take? Continue to use the current intravenous tubing Tell the client the infusion will be administered later in the shift Notify the health care provider to request a new prescription for an intravenous infusion Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing

Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing o The tubing is contaminated and, if the nurse continues to use the current tubing, the bag's contents will become contaminated during infusion. This action will result in harming the client and can increase the risk of an systemic infection, resulting form poor medical and surgical aseptic techniques.

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action? Place the date on the vial and retain for future use. Send the vial with the remaining drug back to the pharmacy. Discard the remaining drug. Draw up the remaining medication to give at the next time of administration.

Place the date on the vial and retain for future use. o The nurse will place the date on the vial and retain it for future use since the vial is indicated for multiple uses. Other actions are incorrect.

A nurse witnesses a peer tell a client, "You are a mother now and you have to do what is best for you baby. You have to breastfeed her!" Which is the best action by the nurse? Fill out an incident report to go in the nurse's personnel file. Approach the client later and provide correct information. Immediately interrupt the conversation and reprimand the nurse. Pull the nurse aside and inquire as to the content of the conversation.

Pull the nurse aside and inquire as to the content of the conversation. o The nurse overheard just a small portion of the conversation between the client and the peer nurse. The best action would be to inquire as to the content of the conversation and then determine if the peer nurse's comments were appropriate. If the comments were inappropriate, the nurse would then need to fill out an incident report.

The registered nurse (RN) has received orders to perform an unsafe practice on a client. The RN voices concern with the physician who gave the order, but the physician refuses to change the order. Whom should the nurse consult next regarding the order? The nurse manager The licensed practice nurse (LPN) The client The charge nurse

The charge nurse o The RN should follow the proper channels for communication and consult the next direct supervisor. The next direct supervisor would be the charge nurse and then the nurse manager. The client and the LPN should not be consulted.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next? The nurse will be suspended and, possibly, terminated from employment at the facility. The incident report will provide a basis for promoting quality care and risk management. The facility will report the incident to the state board of nursing for disciplinary action. The incident will be documented in the nurse's personnel file.

The incident report will provide a basis for promoting quality care and risk management. o Incident reports document unusual occurrences and deviations from care. Facilities use the internal documents to evaluate care, determine potential risks, or discover system problems that might have contributed to the error. This type of error won't result in a report to the state board of nursing or in the nurse's suspension. Some facilities do track the number of errors a nurse or a particular unit makes; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply. Transferring a client to another floor Taking routine vital signs The determination of a nursing diagnosis for a client with breast cancer Planning education for a client with a colostomy Giving a bed bath to a client Administering medications to clients

Transferring a client to another floor Taking routine vital signs Giving a bed bath to a client o The nurse should be familiar with guidelines for delegating nursing care. The nurse could delegate the following tasks to UAP: giving a bed bath to a client, taking routine vital signs, and transferring a client to another floor. The nurse could not delegate the administering of medications, planning client education for a client with a colostomy, or the determination of a nursing diagnosis.

A client has been diagnosed with diabetes and has received instructions about managing the disease. The client has undertaken an activity to improve quality of life and maintain functional status. The nurse recognizes this activity as Ingesting foods with low caloric value Checking blood glucose level twice a day Taking medications as prescribed Walking at least one mile 5 days each week

Walking at least one mile 5 days each week o Behaviors, such as exercise or walking, are essential to quality of life and maintaining functional status for a client who has a chronic illness. The other activities, such as ingesting low caloric foods, taking medications, and checking blood glucose level, relate to managing symptoms and avoiding complications.

A client develops atrial fibrillation following an acute myocardial infarction. The physician orders digoxin, 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to a decreased serum CK level. a decreased serum digoxin level. an increased serum creatinine level. an increased serum creatine kinase (CK) level.

an increased serum creatine kinase (CK) level. o I.M. administration of digoxin isn't recommended because it causes severe pain at the injection site and increases serum CK, which complicates interpretation of enzyme levels. Regardless of the route of administration, digoxin doesn't increase the serum creatinine level. When digoxin is administered, the serum digoxin level will rise from zero, not decrease.

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality? making sure the client's name and date of birth are displayed on the fax cover sheet obtaining a written order from the client's primary physician to fax the information reading all information to the client before faxing determining that the client has authorized release of the information

determining that the client has authorized release of the information o 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 charge nurse is transcribing an order into the electronic medical record (EMR). The order is written atorvastatin 20mg PO QOD x 3. How should the order be written to prevent a medication error? every other day x 3 every other day x 3 days every other day every other day times 3 days every other day times 3

every other day x 3 o Every other day x 3 comprises of 5 days total, and every other day the medication is given. Every other day times (x) 3 days comprises of only 3 days, administering the medication every other day for a total of 2 doses. Every other day times 3 the client would be administered the drug every other day for 3 doses. Every other day has no definite stop date.

If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to document the discrepancy on a opioid-inventory form. document the discrepancy on an incident report. immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy. investigate and correct the discrepancy, if possible, before proceeding.

immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy. o Reporting a noted discrepancy to the nurse-manager, nursing supervisor, and pharmacy should be the nurse's first step. Although the discrepancy may be easily corrected if investigated, the investigation isn't a nurse's responsibility. Documenting the discrepancy on an incident report or opioid-inventory form doesn't address the problem.

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alfa as alternatives to a blood transfusion. Which response by the nurse causes the supervising nurse to plan a review of professional and ethical standards? "Do you have all the information you need for informed consent?" "Do you have any questions that I can clarify for you?" "Tell me how the nurse educator explained the procedure." "You should take the unit of blood. It will help you feel better."

"You should take the unit of blood. It will help you feel better." o Stating that the client should accept a blood transfusion is a violation of professional and ethical standards since the nurse is exercising undue influence on the client's choice. Therefore, if the nurse gives this response, a review of standards is needed. To give informed consent, the client must have all the information and understand it, and all of the client's questions should be answered. The other statements would indicate that the nurse understands this principle.

The nurse is preparing a client for a laser procedure. Which nursing intervention is appropriate? Cleanse the procedure area with alcohol. Remove the client's nail polish with acetone before the procedure. Prepare the surgical tray with silver instruments. Apply goggles to the client.

Apply goggles to the client. o The client, and all who are involved in the procedure, will wear goggles. Alcohol and acetone should not be used around lasers due to flammability. Therefore, the nurse should not remove the client's nail polish with acetone, nor clean the area with alcohol, before the procedure. Surgical instruments used should be coated in black to avoid heat retention. Therefore, the surgical tray should not be prepared with silver instruments.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order? Ask if the client would prefer to have an enema administered. Ask what type of laxative the client would like to have. Give mineral oil because it does not require a physician's order. Ask the physician to prescribe a specific laxative.

Ask the physician to prescribe a specific laxative. o The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug. The other options are incorrect because they put the nurse in the position of prescribing a medication and not following established professional standards for the administration of medication.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Continue the assessment because no actions are indicated at this time. Document the reading because it reflects that the treatment has been effective. Check the equipment. Contact the physician to review the care plan.

Check the equipment. o A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step? Document on the consent form that the client is unable to sign the consent because of being legally blind. Contact the client's nearest relative to obtain consent. Make sure the client's family is present when the consent form is signed. Read the consent form to the client and ask if there are any questions.

Read the consent form to the client and ask if there are any questions. o The nurse should read the consent form to the client and make sure that the client understands all the information. The healthcare provider should answer any questions the client has before the consent form is signed. The client's family doesn't need to be present, and there is no need to contact the client's closest relative. A client who is legally blind may sign the consent form.

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate? Answer the client's questions. Place the consent form in the client's medical record. Notify the nurse manager of the client's questions. Request that the surgeon come and answer the questions.

Request that the surgeon come and answer the questions. o It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all of the client's questions are answered fully.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent? Contact the hospital chaplain to sign the consent on the client's behalf. Ask the nursing supervisor to contact the hospital lawyer. Keep the client in the emergency department until the family is contacted. Take the client to the operating room for surgery without informed consent.

Take the client to the operating room for surgery without informed consent. o All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed. The nurse should take the client to the operating room.

A nurse is planning the discharge of a newborn to parents recently immigrated from Syria. Which action best indicates that the nurse provides culturally sensitive care? The nurse strives to keep the clients' cultural background from influencing their health needs. The nurse approaches the clients in a nonjudgmental way in an attempt to change the clients' cultural beliefs to the unit's beliefs. The nurse encourages the continuation of cultural practices in their home setting. The nurse researches the clients' cultural characteristics and beliefs.

The nurse researches the clients' cultural characteristics and beliefs. o Nurses must research and understand the cultural characteristics, values, and beliefs of the various people to whom they deliver care. To provide culturally appropriate care to diverse populations, nurses need to know, understand, and respect culturally influenced health behaviors.

If a medication is being administered by the otic route, it will be administered in which way? Lubricated and gently placed into the rectum Warmed to room temperature and dropped into the ear Warmed to room temperature and dropped into the eye Rolled between the hands and drawn up into a small syringe

Warmed to room temperature and dropped into the ear o Otic means ear. Be sure that the ear drops are at room temperature. If necessary, roll the container between the palms of your hands to help warm the drops. Using cold ear drops can cause pain and possibly vertigo or vomiting when they reach the eardrum. If the medication were to be placed in the rectum the instructions would say "for rectal use only." A ophthalmic drug would be placed in the eye. Medications in a syringe could be for injection or a liquid for oral use.

A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP? "Why weren't you there to help the client get to the bathroom?" "Your behavior in this situation is considered verbal abuse." "You need to have more training in therapeutic communication." "I'm sure you didn't mean to hurt the client's feelings, but you did."

"Your behavior in this situation is considered verbal abuse." o Reprimanding a client for something that is beyond the client's control is considered abusive. The other options do not help the UCP understand the abusive behavior.

The nurse is preparing to administer regular insulin to a nonverbal pediatric client. Which action will the nurse perform prior to administering the medication? Check the full name and birth date on the client's wristband with the medication administration record. Check the full name and room number on the client's wristband with the medication administration record. Check the full name and age on the client's wristband with the medication administration record and have the parent verbally confirm. Check the birth date and full name on the client's wristband with the medication administration record and have another nurse verify.

Check the full name and birth date on the client's wristband with the medication administration record. o When administering medications to a child, the nurse needs to use at minimum two client identifiers that are directly associated with the client and the medication to be given, such as full name, client ID number, and birth date. The nurse will take the medication administration record to the room to perform a "double-identifier" check. A client's identity must be verified with two acceptable identifiers, not just one. There is no need to have another nurse verify or have the parent state the client's information. A room number or a bed number is not an acceptable identifier.

The nurse is reviewing the physician's order written for a postmenopausal client: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order? Clarify with the physician that the spray should be given in only one nostril per day. Inform the physician that the medication is not a nasally applied medication. Ask the physician why this medication was ordered for a postmenopausal client. Remind the physician that this medication can be purchased over-the-counter.

Clarify with the physician that the spray should be given in only one nostril per day. o Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print "administer in both nostrils" when a nasal spray is ordered. Nurses must be familiar with the directions for each medication they give before administering medications. The other options are incorrect because calcitonin salmon nasal spray is prescribed to postmenopausal clients for the treatment of osteoporosis and requires a physician's order.

The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action? Administer the drug as ordered. Contact the health care provider for order clarification. Ask another nurse to verify the order. Assume that the provider meant to order buspirone.

Contact the health care provider for order clarification. o The nurse should contact the health care provider to verify the order. Bupropion and buspirone are drugs that have look-alike and sound-alike properties but are different in indication. The nurse should not automatically administer the drug, nor ask another nurse to verify an order, nor assume what is meant by an order.

What is the nurse accountable for, according to state nurse practice acts? Mentoring other nurses Managing the care team effectively Making nursing diagnoses Prescribing PRN (as needed) medications

Making nursing diagnoses o State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held individually accountable. Overall management of the care team is not an explicit responsibility of nurses. Nurses generally do not have prescriptive authority. The responsibility for mentorship is not enacted in law.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? Nurses do carry out interventions in response to a physician's order. Nurses do not carry out physician-initiated interventions. Nurses are responsible for reminding physicians to implement orders. Nurses are not legally responsible for these interventions.

Nurses do carry out interventions in response to a physician's order. o A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding physicians to implement orders, nurses may request a physician to implement an order or question an existing order by the physician if the nurse believes it is in the client's best interests.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem? Ask for a meeting with the coworker and a manager. Correct the problem and submit a written report. Speak to the coworker upon return to the unit. Inform the nurse supervisor right away.

Speak to the coworker upon return to the unit. o When a nurse discovers substandard practice by another nurse, it is always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse supervisor first does not promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issue can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

The nurse just started an infusion of blood on a client. A few minutes pass and the client develops a sudden fever. What are the priority interventions by the nurse? Select all that apply. Stop the blood infusion. Force oral fluids. Continue to monitor vital signs. Notify the health care provider. Start the normal saline infusion.

Stop the blood infusion. Continue to monitor vital signs. Notify the health care provider. Start the normal saline infusion. o Development of fever during blood transfusion can indicate a transfusion reaction. The appropriate nursing action is to discontinue the blood transfusion, infuse normal saline to prevent a more severe reaction, continue to monitor vital signs, and call the healthcare provider. Other interventions include serum analysis of BUN and creatinine, and returning the blood and tubing to the laboratory to be analyzed. Forcing oral fluids is not part of transfusion reaction care.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? Provide a list of approved visitors who came spend time with the infant. Check the name on the baby's identification bracelet. Check the identification badge of any health care worker before releasing baby from room. Send a family member to accompany the infant when leaving the room.

Check the name on the baby's identification bracelet. o Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client? The student nurse The nurse instructor The student nurse, the nurse instructor, and the hospital The hospital

The student nurse, the nurse instructor, and the hospital o As a student nurse, you are responsible for your own acts, including any negligence that may result in client injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. The status of students enrolled in college and university programs is less clear, as is the liability of the educational institution in which they are enrolled and the health care agency offering a site for clinical practice. Nursing instructors may share responsibility for damages in the event of client injury if an assignment called for clinical skills beyond a student's competency, or the instructor failed to provide reasonable and prudent clinical supervision.

Which nursing intervention demonstrates congruence in a therapeutic nurse-client relationship? implementing restatement as a therapeutic communication method getting an appointment with the client at the time previously agreed upon sharing examples of stress management techniques discussing the client's request for additional privileges with the treatment team

getting an appointment with the client at the time previously agreed upon o Congruence occurs when words and actions match. The nurse demonstrates this by fulfilling the promise made to the client. While the remaining options are appropriate behaviors that positively affect the nurse-client relationship, they do not demonstrate congruence.

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response? "I will not work tomorrow because I want to have a day off." "I will work tomorrow because short-staffing is dangerous for the clients." "I will work tomorrow because the other nurses need my help." "I will not work tomorrow because I would be a danger to my clients."

"I will not work tomorrow because I would be a danger to my clients." o The nurse cannot care for client without first ensuring self-care. The nurse is tired and most appropriately is declining to work because the nurse will not be able to function at full capacity. Simply stating that the nurse wants a day off does not fully address the situation. The option of working tomorrow is not appropriate because the nurse needs to rest after working a night shift.

After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom the student nurse has been assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response? Allow the student access to the medication record because the instructor has posted an assignment sheet. Allow the student supervised access to the client's medication record. Ask the student to provide a photo ID for comparison with the names on the assignment sheet. Ask the student to contact the instructor by phone to verify the student's identification.

Ask the student to provide a photo ID for comparison with the names on the assignment sheet. o Most facilities require photo identification to maintain security and confidentiality. Allowing a student without an ID to have supervised access to a medication record doesn't protect client information. Contacting the instructor by phone doesn't verify the student's identity.

A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs? Report the vital signs and allow the emergency room physician to determine the significance. Consult reference materials to determine the normal vital signs for 1-month old infants. Ask the mother if the infant's heart rate is higher than normal. Perform a complete physical assessment to determine the cause of the elevated vital signs.

Consult reference materials to determine the normal vital signs for 1-month old infants. o It is part of nursing practice to interpret the significance of assessment data by comparing it to standards. The nurse should consult reference materials to determine the normal range of vital signs for this client. Deferring to the emergency room physician is unprofessional and may result in harm to the client. Asking the mother if the infant's vital signs are higher than normal is unprofessional practice. A complete physical assessment is not necessary at this time.

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? a 6-month-old infant who has gastroenteritis and vomits every 30 minutes a 2-year-old child who nearly drowned 2 days earlier a 19-month-old infant who had surgery for a fractured tibia 12 hours ago a 17-month-old infant who lost consciousness 2 hours earlier because of a head injury

a 2-year-old child who nearly drowned 2 days earlier o The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. The child's status could quickly become very critical.

A client has been diagnosed with an infection. The nurse can help to ensure the success of anti-infective treatment by: monitoring the client closely for signs of arrhythmias or cardiac ischemia. teaching the client that significant adverse effects are expected, and must be endured during treatment. administering antihistamines, as ordered, to prevent the development of adverse effects. confirming that the medication prescribed is the drug of choice for the specific microorganism.

confirming that the medication prescribed is the drug of choice for the specific microorganism. o In order for treatment to be effective, it is necessary for an anti-infective to be accurately matched to the offending pathogen. Anti-infectives do not normally cause cardiac adverse effects. The client should be taught that adverse effects can be managed and are not necessarily an inevitability that must be endured. Antihistamines do not prevent most adverse effects.

When a nurse attempts to make sure the health care provider obtained informed consent for a thyroidectomy, the nurse realizes the client doesn't fully understand the surgery. The nurse approaches the health care provider, who curtly says, "I've told this client all about it. Just get the consent." The nurse should: tell the health care provider the nurse cannot obtain informed consent at this point. tell the health care provider: "You didn't give the client enough information." explain the procedure more fully to the client and obtain the client's signature. ask the charge nurse to talk with the health care provider.

tell the health care provider the nurse cannot obtain informed consent at this point. o The nurse has evaluated the client's knowledge concerning the surgery and determined that the client doesn't have enough information to give informed consent. Even though the health care provider (HCP) wants to move ahead, the nurse should advocate for the client by asserting that the client isn't ready for the surgery. Stating that the HCP did not provide enough information is unlikely to gain the provider's cooperation and may be untrue: the HCP may have provided comprehensive information, but the client did not comprehend it all and requires further education. The nurse should not ask the charge nurse to talk with the HCP unless the HCP refuses to accept the nurse's professional opinion. Explaining surgery for the purpose of obtaining consent is beyond the nurse's scope of practice.

A charge nurse asks a group of staff nurses to cover part of the next shift because a nurse called off. A staff nurse states, "40 hours a week of nursing is all I can manage. I won't volunteer for overtime." The charge nurse tells the unit's nurse manager, "You should adjust her schedule to make her wish she'd volunteered." How should the nurse manager respond? Counsel the charge nurse about her comment. Report the charge nurse to the nursing administration. Ignore the comment because the charge nurse made the statement under stress. Tell the staff nurse what the charge nurse said about her.

Counsel the charge nurse about her comment. o It would be discriminatory and punitive for the nurse manager to alter the staff nurse's schedule. The remark by the charge nurse is inappropriate and unprofessional, and the charge nurse should receive counseling. The nurse manager could choose to ignore the comment, but any leader who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the charge nurse to the nursing administration should be avoided. Institutional documentation should exist for such matters. It is inappropriate for the nurse manager to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? Create the client assignment by considering available staff's skill level and client needs. Call charge nurses on other units to request a registered nurse come assist on the unit. Notify the local nursing regulating body about the unsafe working conditions at the facility. Refuse to create the client assignment and tell management that a nurse must be found.

Create the client assignment by considering available staff's skill level and client needs. o When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members. The charge nurse's primary duty is to the safety of the clients. If there were serious impediments to safely adjusting the workload, it may be reasonable to voice this concern to the management, but the priority is to attempt to create the safe client assignment within the current staffing realities. The nurse should not attempt to arrange for staffing independently by calling other charge nurses as this is outside the role and responsibilities and may create safety concerns on other units. If the working conditions are considered unsafe, this could be a matter to be brought forward to a regulating body. However, in the moment, the charge nurse's priority is to attempt to distribute the clients' care in a safe manner.

Which would be included as a responsibility of the scrub nurse? Coordinating activities of other personnel Keeping all records and adjusting lights Handing instruments to the surgeon and assistants Obtaining and opening wrapped sterile equipment

Handing instruments to the surgeon and assistants o The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel.

The nurse notes that a colleague neglects to wipe away the first drop of blood from the sample during point-of-care blood glucose testing; this in contradiction of the unit policy. What action should the nurse take first? Retake the blood glucose on the client to ensure a more accurate result for guiding treatment decisions. Remind the colleague that by failing to adhere to unit policy, the colleague will be at risk of disciplinary action. Remind the colleague that the purpose of discarding the first drop is to improve the reliability of the results. Report the colleague to the nurse in charge so that retraining on using the glucometer can be arranged.

Remind the colleague that the purpose of discarding the first drop is to improve the reliability of the results. o Reliability of a diagnostic result depends on a combination of the tools being used and the person's skill in taking the measurements. If the colleague does not perform the steps correctly, the reliability of the results are in question. The nurse should remind the colleague as to why the step of wiping away the initial drop is important for reliability. This approach is the most direct and professional of the options provided. Reporting the colleague to the nurse in charge would only be needed if the colleague did not heed the nurse's direction. Retaking the sample without first explaining to the colleague why the nurse was taking the action would be confusing for the colleague and the client. Threatening the nurse regarding disciplinary action is not necessary in this scenario.

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind? Do not share inferences with the client. Avoid making any inferences. Validate inferences with the client. Document all inferences.

Validate inferences with the client. o The nurse should validate inferences made from assessment data to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and client plans of care. Making inferences can be helpful as long as the nurse validates them. It is not necessary to document inferences. Often, the nurse must share inferences with the client to validate them.

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order? Obtain confirmation of the order from a physician or nurse practitioner present on the unit. Write out the order, the physician's name, the nurse's name, and the name of a witness. Record the order verbatim in the client's charts and follow it with the nurse's printed name and signature alone. Write "T.O." after the order and write out the physician's and nurse's names.

Write "T.O." after the order and write out the physician's and nurse's names. o When receiving telephone orders, the nurse should record the orders in the client's medical record, read the order back to the ordering practitioner, date and note the time the orders were issued, record T.O. (telephone orders) and the full name and title of the physician or nurse practitioner who issued the orders, and then sign the orders with name and title. It is unnecessary to obtain a confirmation from another practitioner or to have the order witnessed.

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply. "Our surgical team would never make that mistake." "The client will be involved in the verification process prior to surgery." "The surgeon on the team has never been involved in such a mix-up." "The client can be involved in marking the knee, the site for the surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification."

"The client will be involved in the verification process prior to surgery." "The client can be involved in marking the knee, the site for the surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." o There is an increased emphasis on making sure that the right client has the right procedure at the right site. To prevent "wrong site, wrong procedure, wrong person surgery," The Joint Commission (2019) established a universal protocol to achieve this goal. Included in this checklist are steps to verify the preoperative process, mark the operative site, and perform a "time-out." Telling the client that the surgeon has not been involved in such a mix-up or would never make that mistake is false reassurance.

The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action? Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription. Input the prescription into the electronic medical record (EMR) to reflect that the drug is given every 8 hours, after verifying with the pharmacy. Ask another nurse to validate the frequency as every 8 hours, update the electronic medical record (EMR), flagging the prescription for the health care provider to review and cosign the prescription within 24 hours. Ask the nursing supervisor to validate the frequency as every 8 hours and update the electronic medical record (EMR).

Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription. o The nurse should always have the health care provider clarify the prescription. The nurse cannot assume that a medication is to be given at certain times, nor should another nurse verify the frequency or clarify the prescription. The nurse should remain on the phone with the provider and read back the entire prescription for verification. Documentation should reflect that it is a phone prescription. Usually the phone prescription has to be reviewed and cosigned by the provider within 24 hours.

While caring for a client from a culture different from the nurse's, the nurse inadvertently offends the client. What is the best action by the nurse? Examine the interaction and focus on the majority culture. Recognize that there is a cultural bias that led to the mistake. Learn from the mistake and do not repeat it. Ask the client why the client is so mad.

Learn from the mistake and do not repeat it. o All nurses make mistakes at some time when caring for culturally diverse clients. The best action is to learn from the mistake and not repeat the offense. Although it may be appropriate to discuss with the client, asking why the client is so mad is aggressive and may make the situation worse. The mistake was inadvertent and may not be the result of cultural bias. Focusing on your own majority culture will not help bring about learning associated with the mistake.

The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just don't feel good." What actions should the nurse take? Select all that apply. Place the client in the semi-Fowler's position. Make a quick check on other assigned clients before spending the time required to take care of this client. Call the health care provider (HCP) and report the situation using SBAR format. Confirm the client's vital signs and complete a quick assessment. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. Stay with and reassure the client.

Place the client in the semi-Fowler's position. Call the health care provider (HCP) and report the situation using SBAR format. Confirm the client's vital signs and complete a quick assessment. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. Stay with and reassure the client. o The nurse must have assessment data and verify vital signs if necessary in order to determine the action that is required. If there is a significant change in the client's condition, the charge nurse should be notified in order to help the nurse with both this client and the nurse's other assigned clients if necessary; most acute care facilities have a rapid response team that can also help assess and intervene with basic standing prescriptions if necessary. Positioning the client in semi-Fowler's is a nursing action that may assist in breathing and relieve shortness of breath. It is important for the nurse to reassure the client by staying calm and remaining with the client. The nurse must notify the HCP about the change in client's condition; the nurse must have all information available and present it in a concise and accurate manner using SBAR format including a recommendation for treatment if indicated. The nurse should stay with this client and delegate checking on other assigned clients to the charge nurse or UAP.

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that: the main focus is on monitoring the body's pathophysiologic response. the signs and symptoms of the disease are part of the information conveyed. the problem's existence requires validation by the physician. the interventions planned must be within the nurse's scope of practice.

the interventions planned must be within the nurse's scope of practice. o A nursing diagnosis describes an actual, risk, or health promotion response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the physician that the problem exists, are focused on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.