3010 Exam 1

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 Your elderly client appears withdrawn around his daughter and has questionable bruises.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? Tell the client's daughter "how dare you abuse your father" Ask for advice from another nurse on the floor Notify the nursing supervisor for further guidance. Ask the daughter to leave

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Which one of the following is the nurse's best legal safeguard? malpractice insurance Patient education Union contract Competent, safe practice

Competent, safe practice

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

Negligence

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

Physician

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 verbalizes items needed and how to perform the skill. The client organizes materials needed and gives return demonstration The client states understanding and passes a written test. The client nods when asked about process and assists with cleanup

The client organizes materials needed and gives return demonstration

A nurse is providing patient care in a hospital setting. Who has responsibility and accountability for the nurse's actions? The nurse The head nurse (or charge nurse) The hospital The physician

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 informs the family about advance directives. The nurse ensures that the client signs the consent form. The nurse ensures that the client's family signs the consent form. The nurse informs the family about the living will.

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

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? "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with family." "It's okay to discuss these things with your best friend, but not on social media." "You may continue to post about a client, as long as you do not use the client's name." "Any information that can identify a person is considered a breach of client privacy."

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

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 am so sorry you are going through this." "Sitting in the dark is not going to cure your cancer. Let's open the curtains." "I know this is hard for you. Is there any way I can help?" "Can you please tell me why you are crying?"

"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." "It's the fault of the previous nurse, who left it for me to do." "You should have written your order more clearly than you did." "I have other patients and have been very busy today."

"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? "You should ask some of the more experienced nurses this question." "If I were you, I would not have this surgical procedure." "Let me talk to your doctor, and I will let you know what I find out." "Tell me why you do not want the surgery."

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

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." "I think the client would benefit from intravenous furosemide." "It seems like this client has fluid volume overload." "I am calling because the client receiving blood has developed dyspnea and had crackles."

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

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? "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "The client was admitted today with a urinary tract infection." "Will you prescribe a complete blood count to check the white blood cell count and a culture?" "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

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

You have four clients with discharge orders. Which client below would you want to suggest homecare for? A 46 year old who uses illegal drugs. An 80 year old who has used a walker for years. A 40 year old diabetic who needs assistance getting to the restroom. A 59 year old client who is a left lower leg amputee who had an appendectomy and has been ambulating okay.

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

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? Proof of health care power of attorney A living will A living will An order for Do Not Resuscitate (DNR)

A living will

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 Avoiding treating the client so as to not do any additional harm Telling the client honest information about the client's medical condition and prognosis Filing the paperwork for the client to receive retroactive health insurance

Airlifting the client to a local trauma center for emergency surgery

To practice ethically, the nurse should avoid: Reviewing past cases before making decisions about practice. Asking the client's family about their views on caring. Allowing the nurse's own judgment to guide practice. Allowing an ethics committee to guide the nurse's practice

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? Battery Negligence Assault Defamation

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. Replace one-on-one teaching with written materials. Boost the morale of the client. Delegate the health education to a colleague

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? Convince the family to choose a specific course of action. Present options about the type of care. Assist in decision making based on the client's best interests. Decide the care for a client who is unable to voice an opinion.

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

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 Standards of care from experts in the practice field Nurse Practice Act (NPA) written by state legislation Good Samaritan laws for civil guidelines

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? Values clarification Definition of nursing Code of Ethics for Nursing Standards of care

Code of Ethics for Nursing

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 Arriving on time to work consistently A decrease in personal hygiene and appearance Adherence to completing work assignment

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

The nurse has inadvertently administered medication ordered for Client A to Client B. What is the appropriate nursing action? Select all that apply. Contact the provider to report the error. Complete an incident report. Do nothing as long as Client B has no reaction. Assess Client B thoroughly. Tell Client A that the wrong drugs were given to Client B.

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

A nurse forgot to document that a client drank 120ml of water at 0830. It is now 1030. What action should the nurse take? Do not document this water since too much time has lapsed. Fill out an incident report. Document the water for the 0830 time Document the water for the 1030 time.

Document the water for the 0830 time

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. Lecture provided about infection, and client stated understanding what infection is. Spouse taught to flush feeding tube before and after medication. Denied further instruction needed. Discussed wet-to-dry dressing changes, and client stated understanding.

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? Uncertainty Dilemma Dissatisfaction Distress

Distress

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

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

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. Consult with the hospital's legal department as soon as possible. Enlist support from nursing and non-nursing colleagues from the unit. Consult with practice advisors from the state board of nursing.

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

When signing a form as a witness, your signature shows that the client: Was free to sign without pressure Is fully informed and is aware of all consequences. Was awake and fully alert and not medicated with narcotics. Has signed that form and the witness saw it being done

Has signed that form and the witness saw it being done

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? Direct the spouse to online databases such as the Cumulative Index to Nursing and Allied Health Literature. This is unfortunately not something we currently do for clients in the hospital. Encourage the spouse to avoid online resources due to the unregulated nature of the Internet. Identify and recommend some credible websites appropriate to the spouse's learning needs.

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

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 Defamation of character Negligence of duty Unintentional tort

Invasion of privacy

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? Slander fraud Invasion of privacy Assault

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 limits personal safety. It increases confusion. It threatens autonomy. It prevents self-directed care.

It threatens autonomy.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. Keeping record of people who have access to clients' records Making the names of clients on charts visible to the public Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Obscuring identifiable names of clients and private information about clients on clipboards Posting information linking a client with diagnosis, treatment, and procedure on whiteboards at nurses station

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

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 two cats at home; the client's mother is taking care of the cats No new labs have been ordered after surgery. The client has a clean and dry abdominal dressing. The client's hobby is modeling, which we had a conversation about. Ms. J-Lo is in Room 7, admitted postoperatively for an open appendectomy. Pain level is currently a 2 following administration of intravenous morphine.

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

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

Nonmaleficence

Most litigation in the hospital comes from the: Supervisor watching a new employee check his or her skills level Nurse following an order that is incomplete or incorrect Nurse abandoning the clients when going to lunch Nurse documenting blame on the physician when a mistake is made

Nurse following an order that is incomplete or incorrect

What is an example of the doctrine of double effect? Health care provider advises patient of two different treatments. Physician orders the less expensive of two tests. A medical error doubles the cost of the patient's hospital stay. Nurse gives ordered high dose of morphine to dying patient.

Nurse gives ordered high dose of morphine to dying patient.

The scope of Nursing practice is legally defined by: Professional nursing organizations Hospital policy and procedure manuals Physicians in the employing institutions State nurses practice acts

State nurses practice acts

Which situation is an example of battery that the nurse may witness while performing duties at the health care facility? Verbal violence towards another nurse. Taking the client's photograph without consent Performing a surgical procedure without getting consent Telling the client that the client may not leave the hospital

Performing a surgical procedure without getting consent

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. Refuse to administer the medication Document concerns about the order Administer the medication based on the order.

Question the order for the medication.

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? Explain that only a paper copy of the health care record can be viewed by the client. Access the health care record at the bedside and show the client how to navigate the electronic health record Review the hospital's process for allowing clients to view their health care records. Discuss how the hospital can be fined for allowing clients to view their health care records.

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? Refer the situation to the nursing supervisor The nurse should not stand in the way of the family wishes. Discuss the situation with a colleague at another hospital. Review the literature about providing pain relief with the family.

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? Have the interpreter write out all of the information listed in the unit brochure. Give all of the discharge instructions at once. Ensure that family members are present. Speak directly to the client.

Speak directly to the client.

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. The nurse must follow the physician's orders. The nurse is unable to provide care for the client. The physician's order creates a barrier to establishing an effective nurse-client relationship.

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 Purposive communication Intrapersonal communication Metacommunication

Therapeutic communication

Which actions should the nurse take to ensure that client information remains confidential? Select all that apply. Verify the number in the fax machine as correct prior to transmission. Exit the client's room when called on the hospital-issued cell phone about another client on the team. Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. Access client information on the portable computer in the hallway where visitors are present. Print client information to a printer shared with another unit.

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

You notice another nurse on the floor not wearing gloves when helping a client use the restroom. How do you react? This is acceptable behavior if you can guarantee you won't get any bodily fluids on you. You should let the nurse know they must use gloves and wash their hands before and after patient care. Immediately tell the nursing supervisor. She is your best friend on the floor so you don't say anything right now.

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

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

autonomy