Accountability

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 of the following would be considered subjective data?

"Client seems very nauseated."

A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which of the following would be the most appropriate response by the nurse to the surgeon?

"It is your responsibility to obtain informed consent from the client." Correct

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 alpa as alternatives to a blood transfusion. Which of the following responses by the nurse causes the supervising nurse to plan a review of professional and ethical standards?

"You should take the unit of blood. It will help you feel better."

A staffing agency is sending a licensed practical nurse (LPN) to cover a shift for a pediatric nurse who called out sick. The unit's nurse-manager isn't familiar with the LPN's clinical background or comfort level with pediatric clients. The nurse-manager should assign the LPN to:

A 9-year-old child receiving subcutaneous insulin for treatment of diabetes mellitus. Explanation: The nurse-manager should assign the LPN to the child with diabetes mellitus. Because he's receiving subcutaneous insulin rather than I.V. insulin, his diabetes is likely stable. Reye's syndrome is an acute condition with the potential to progress into respiratory depression, seizures, loss of deep tendon reflexes, or other neurologic deficits. This child will require frequent nursing assessments. The child who had a tonsillectomy remains at risk for hemorrhage during the first 24 hours following surgery. Legg-Calve'-Perthes Disease is associated with impaired circulation to the femoral capital epiphysis. This condition requires aggressive monitoring.

A patient accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting patient care on the patient record

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?

Address the nurse's omissions as negligent behavior.

The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. What action should the nurse take first?

Assess the client's injury, notify the physician, and document the incident.

During an emergency, a physician has asked for I.V. calcium to treat a client with hypocalcemia. The nurse should:

Check with the physician for his complete order.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse

The nurse is working with a client who has difficulty controlling her blood sugar. The overweight client does not adhere to a low-calorie diet and forgets to take medications and check her blood glucose level. The client's glycohemoglobin is 8.5%. When establishing a goal for the client, the nurse first

Collaborates with the client to establish an agreed-upon goal

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.

In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant?

Dispose of the disconnected IV set.

A nurse is named as a defendant in a malpractice lawsuit. Which action would be recommended for this nurse?

Do not volunteer any information on the witness stand.

Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system include:

Documenting the client's response to pain medication.

When the nurse recognizes that he has documented one client's assessment data on the wrong client's medical record, the nurse should

Draw a single line through the error, initial it, and write the correct entry.

While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which response by the nurse would be most appropriate?

Explain to the client that "Nurses are not allowed to discuss other clients on the unit."

The nurse is caring for several clients experiencing acute pain. Which of the following would be the most appropriate task to delegate to the unlicensed assistive personnel?

Give the client a back massage.

The nurse is observing a nursing assistant leave the room of patient diagnosed with Clostridium difficile (C. difficile) without washing hands. Which of the following is the highest priority action the nurse should follow?

Have the nursing assistant wash hands with soap and water.

The unit will be short-staffed tomorrow and the charge nurse wants the nurse to work the next day. What is the nurse's most appropriate response?

I will not work tomorrow because I would be a danger to my clients.

Which style of leadership is rarely used in a hospital setting because of the difficulty of task achievement by independent nurses?

Laissez-faire

While caring for an infant, the nurse hears another child screaming in the next room. She rushes to the other room to check on the screaming child, forgetting to put the side rails up on the infant's crib. She returns to the room to find the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for?

Malpractice

A nurse suspects that a coworker is self-administering illegal drugs during work hours. What is the first action the nurse should take?

Notify the nurse manager and document the situation.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?

Notify the surgeon and await his/her decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.

Which level of health care provider may make the decision to apply physical restraints to a client?

Nurse practitioner

A nurse-manager for a community health organization is planning for the home health needs of an 8-year-old child who requires around-the-clock care by nursing assistants. The nurse-manager knows that when working with a nursing assistant, she must:

Provide written instructions, education, and ongoing supervision.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the physician obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step?

Read the consent form to the client and ask him if he has any questions.

A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse?

Refuse to administer the placebo to the client.

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that she forgot to administer insulin to client with diabetes mellitus. She's made numerous errors in the past few weeks and is now afraid her job is in jeopardy. What is her best course of action?

Report the error, complete the proper paperwork, and meet with the unit manager

A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions.

A nurse finds that a fire has broken out in a client's room at the health care facility. Which of the following interventions is of the highest priority?

Rescue the client.

A nurse is having lunch in the break room and overhears the other nurses talking about a difficult client in an inappropriate way. The nurses attempt to engage them in the conversation. Which of the following responses by the nurse would best represent behavior that supports the value of human dignity in nursing practice?

Saying that she believes that this discussion is inappropriate and disrespectful to the client and that she does not want to be a part of it.

Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task?

Scheduling staff assignments for the next month Explanation: Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff, who don't have the power and authority to take such actions.

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 of the following actions should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician?

The nurse.

The registered nurse (RN) wants to delegate measuring a client's urinary output to an unlicensed assistive personnel (UAP). Which factors should the nurse consider before delegating the task?

The stability of the patient?s condition, potential for harm, and complexity of the activity

Which of these statements regarding a nurse manager role is accurate?

To effectively manage the nursing unit, the nurse manager should also be a leader

A 13-year-old is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do?

Verify that the site, side, and level are marked.

A nurse would perform handwashing instead of using an alcohol-based product for which situation?

When hands are visibly soiled from client care

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who is 1 day postpartum. Which tasks would be appropriate to delegate to this person? Select all that apply.

• reinforcing good hygiene while assisting the client with washing the perineum • assisting the client with ambulation shortly after birth • changing the perineal pad and reporting the drainage