226 exam 1

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 should the nurse document on the occurrence report? A.The client fell out of bed. B.The client climbed over the side rails. C.The client was found lying on the floor. D.The client became restless and tried to get out of bed.

C

the nurse is gathering data on a patient. which data will the nurse report as objective data? a. states "doesn't feel good" b. reports a headache c. respirations 16 d. nauseated

C

how often do you need a new restraint prescription

every 24hrs

battery

intentional touching of another's body w/o consent

consent

must be signed freely by the client w/o threat or pressure and must be witnessed

what nursing interventions must be done on a patient who is restrained

neurovascular checks every 2 hrs, ROM exercises, skin integrity checks

where should the restraint be tied to

the bed frame, not the side rails

the legal rights of the patient are

the right to: - privacy - considerate and respectful care - be informed - know the names and roles of the persons involved in care - consent or refuse treatement - have an advanced directive - obtain their own medical records and results

slander

verbal damage to someone's reputation

assault

when a person puts another person in fear of a harmful or offensive contact

three important things to do when taking a telephone order

write it down, read it back to provider, receive confirmation from provider that it's correct

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 •2. Battery •3. Slander •4. Invasion of privacy

1

The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks should be assigned to the assistive personnel (AP)? Select all that apply. 1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 pm vital signs on clients 4.Giving medications left by the nurse for the client to take 5.Assisting a client with a urinary drainage catheter into a chair 6.Obtaining a catheterized urinalysis and taking it to the laboratory

1,2,3,5

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1.A client needed a bed bath 2.A client needing to ambulate 3.A client needing packed red blood cells 4.A client requiring assistance with feeding 5.A client needing to have vital signs checked 6.A client needing to use the bedside commode

1,2,4,5,6

The nurse is acting in the role of client advocate in which situations? Select all that apply. 1.Promoting client comfort 2.Demonstrating mutual respect for all nurses 3.Questioning primary health care provider prescriptions 4.Supporting a client decision regarding a health care choice 5.Speaking at a continuing education offering in the community

1,3,4

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? A.Performing a procedure without consent B.Threatening to give a client a medication C.Telling the client that he or she cannot leave the hospital D.Observing care provided to the client without the client's permission

D

a nurse is prioritizing care for four patients. which patient should the nurse see FIRST? a. a patient needing teaching about meds b. a patient with a healed abdominal incision c. a patient with a slight temperature d. a patient with difficulty breathing

D

a nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. which NANDA nursing diagnosis is the HIGHEST priority for this patient? a. risk for impaired skin integrity b. risk for infection c. spiritual distress d. reflex urinary incontinence

D

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1.A client scheduled to receive parenteral nutrition 2.A client who requires assistance with ambulation every four hours 3.A client scheduled for discharge who needs teaching about medications 4.A client with bladder cancer who is scheduled for a cardiac catheterization.

2

how many fingers should fit between the patients wrist and the restraint

2 fingers

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. 1.Libel 2.Battery 3.Assault 4.Slander 5.False Imprisonment

2,3,5

In order to determine if a task can be delegated to someone other than an RN, you can used the pneumonic TAPE which means

teaching assessment planning evaluation RN CANNOT delegate these tasks

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections 4.A client with difficulty swallowing food and fluids

3

justice

the equitable distribution of care

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? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family.

3

nonmaleficence

the obligation to do or cause no harm

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1.A client scheduled to receive a blood transfusion 2.A client with bladder cancer who will be receiving chemotherapy 3.A client newly diagnosed with diabetes mellitus scheduled for discharge 4.A client on bed rest who requires range-of-motion (ROM) exercises every four hours

4

the nurse hears a HCP say to the charge nurse that a certain nurse cannot care for pts because the nurse is stupid and won't follow orders. The HCP also writes in the pt's medical records that the same nurse, by name, is not to care for any of the patients because of incompetence. which torts has the HCP committed? select all that apply a. libel b. slander c. assault d. battery e. invasion of privacy

A, B

which of the following statements correctly describes the evaluation process? select all that apply a. evaluation is an ongoing process b. evaluation usually reveals obvious changes in patients c. evaluation involves making clinical decisions d. evaluation requires the use of assessment skills e. evaluation is only done when a patient's conditions change

A, C, D

malpractice

Negligence by a professional person ex: nurse owed a duty to the client and did not carry out the duty and client was injured because of it

a nurse is discussing the nursing process with a newly licensed nurse. Which of the following is statements by the newly licensed nurse should the nurse identify as appropiate for the planning step of the nursing process? a. i will determine the most important client problems that we should address b. i will review the past medical hx on the clients record to get more info c. i will carry out the new prescriptions from the provider d. i will ask the client if their nausea has resolved

A

the nurse is intervening for a patient with a risk for a urinary infection. which direct care nursing intervention is MOST appropriate? a. teaches proper hand washing technique b. properly cleans the patient's toilet c. transports the urine specimen to the lab d. informs the oncoming nurse during hand-off

A

the patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. which principle in the nursing code of ethics ensures that the nurse will promote the patient cause? a. advocacy b. responsibility c. confidentiality d. accountability

A

while interviewing an older female patient of asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a. consider cultural differences during this assessment b. the patient to make eye contact to determine her affect c. continue with the interview and document that the patient is depressed d. notify the HCP to recommend a psych evaluation

A

what is hipaa for

Set of standards and procedures for the protection of privacy of health information

beneficence

Doing good or causing good to be done; kindly action

what must you first do before putting restraints on a patient

any alternatives such as reorientation, supervision, diversion

if client is declared mentally or emotionally incompetent who can give consent

appointed guardian or durable power of attorney for heath care has legal authority

how quickly do you need a prescription for the restraints

asap or within the hour of placement

false imprisonment

client is not allowed to leave a health care facility when there is no legal justification to detain the client

negligence

conduct that falls below a standard of care

libel

damage to someone's reputation in writing

fidelity

duty to do what one has promised

good samaritan law

health care professionals assist in emergency situations

veracity

obligation to tell the truth

autonomy

respect for an individual's right to self-determination

five rights of delegation

right task right person right circumstance right direction/communication right supervision

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. Afterwards, 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. 2.Call the nursing supervisor for assistance in determining the route of the medication. 3.Administer the medication by the intravenous route because this route usually is used for clients with heart failure. 4. Administer the medication by the oral route, and clarify the prescription once the PHCP has finished addressing the critical care issue in the emergency department.

1

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? She 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." 2."If you want to know about Carol, you need to ask her yourself." 3."Only because you're worried about a friend, I'll tell you that she is improving." 4."Being her friend, you know she is having a difficult time and deserves her privacy."

1

While eating lunch in the hospital cafeteria, a nursing student overhears 2 nurses talking about a client. Which is the important information for the nurses to remember when talking about the client? 1.Talking about clients in public places is a violation of the client's confidentiality. 2.The client's rights to confidentiality do not apply to the break time of employees. 3.It is acceptable for the nurses to talk about a client because they are on the same treatment team. 4. The nurses taking care of the client should not share information with each other that the client has told them separately.

1

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 should inform the AP that making this accusation has violated which legal tort? A.Libel B.Slander C.Assault D.Negligence

B

a recent immigrant who does not speak english is alert but requires hospitalization. what is the initial action that the nurse must take to enable informed consent to be obtained? a. ask a family member to translate what the nurse is saying b. request an official interpreter to explain the terms of consent c. notify the nursing manager that the patient doesn't speak english d. use hand gestures and medical equipment while explaining in english

B

a charge nurse is reviewing outcome statements written by a novice nurse. the nurse is using the SMART approach. which patient outcome statement will the charge nurse identify as appropriate to the new nurse a. the patient will ambulate in hallways b. the nurse will monitor the patient's heart rhythm continuously this shift c. the patient will feed self at all mealtimes today without reports of shortness of breathe d. the nurse will administer pain medication every 4 hours to keep the patient free from discomfort

C

a confused patient with a urinary catheter, NG tube, and IV line keeps touching these needed items for care. the nurse has tried to explain to the patient that these lines should not be touched, but the patient continues. which is the BEST action by the nurse at this time? a. apply restraints loosely on the patient's dominant wrist b. notify the HCP that restraints are needed immediately c. try other approaches to prevent the patient from touching these care items d. allow the patient to pull out lines to prove that the patient needs to be restrained

C

the patient's son requests to view documentation in the medical record. what is the nurse's best response to this request? a. ill be happy to get that for you b. you are not allowed to look at it c. you will need your mother's permission d. i cannot let you see the chart without a doctors note

C

different types of consents include

admission agreement immunization consent blood transfusion consent surgical consent research consent special consents