Fundamentals of Nursing Unit 4

A new graduate nurse is being mentored by a more experienced nurse. They are discussing the ways nurses need to remain active professionally. Which of the statements below indicates the new graduate understands ways to remain involved professionally?

"I am thinking about joining the health committee at my church." "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health."

Match the correct entry with the appropriate SOAP (Subjective—Objective—Assessment—Plan) category. A. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. B. "The pain increases every time I try to turn on my left side." C. Acute pain related to tissue injury from surgical incision. D. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

"The pain increases every time I try to turn on my left side.":S, Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.:O, Acute pain related to tissue injury from surgical incision.:A, Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device.:P

A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? 1. Include communication while performing tasks such as changing dressings and checking vital signs. 2. Ask the patient if you can talk during the last few minutes of visiting hours. 3. Ask Pastoral care to come back a little later in the day. 4. Remind the nurse to complete all her tasks and then set up remaining time for communication.

1

A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase

1

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

1,3

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.

1,3,4

Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.) 1. Gaining an understanding of patient's motivations 2. Focusing on opportunities to avoid poor health choices 3. Recognizing patient's strengths and supporting their efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors

1,3,5

A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange 334is an example of which element of the transactional communication process? 1. Message 2. Obtaining feedback 3. Channel 4. Referent

2

The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) 1. Prevent the nurse from saying the wrong thing 2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight 4. Allow time for the patient to drift off to sleep 5. Determine if the patient would prefer to talk with another staff member

2,3

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies

2,3,4

A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? 1. Challenge the nurses in a public forum to embarrass them and change their behavior 2. Talk with the department secretary and ask if this has been a problem for other nurses 3. Talk with the preceptor or manager and ask for assistance in handling this issue 4. Say nothing and hope things get better

3

A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? 1. "Why did you drive after you had been drinking?" 2. "We have multiple patients to see tonight as a result of this accident." 3. "Tell me what happened before, during, and after the automobile accident tonight." 4. "It will be okay. No one was seriously hurt in the accident."

3

A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? 1. Arrange for a Spanish-speaking social worker to explain the procedure 2. Ask a fellow Spanish-speaking patient to help explain the procedure 3. Use a professional interpreter to provide wound care education in Spanish 4. Ask the patient to write down questions that he or she has for the nurse

3

A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? 1. Validation 2. Empathy 3. Sarcasm 4. Humility

4

A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? 1. Planning 2. Assessment 3. Intervention 4. Evaluation

4

A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PM yesterday. She complains of a poor appetite." 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night."

4S, 1B, 2A, 3R

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry

A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user. Correct Answer(s): C

The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline the nurse will follow?

A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

Which of the follow explain how health care reform is an ethical issue?

A) Access to care is an issue of beneficence, a fundamental principle in health care ethics B) Reforms promote the principle of beneficence, a hallmark of health care ethics C) Purchasing heath care insurance many become an obligation rather than choice, a potential conflict between autonomy and beneficence D) Lack of access to affordable health care causes harm, and non-maleficence is a basic principle of health care ethics Answer: C

The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. What principle would be a priority in a discussion about ethics?

A) Accountability because you as the nurse are accountable for the well-being of this patient B) Respect for autonomy because this patient autonomy will be violated if he does not receive the liver transplant C) Ethics of care because the caring thing that a nurse could provide this patient is resources for liver transplant D) Justice because the first and greatest question in this situation is how to determine the just distribution of resources Answer: D

The point of the ethical principles to "do no harm" is an agreement to reassure the public that in all ways the health care team not only works to heal patients but agree to do this in the least painful and harmful way possible. Which principle describes this agreement?

A) Beneficence B) Accountability C) Non-Maleficence D) Respect for Autonomy Answer: C

Ethical dilemmas often arise over a conflict of opinion. What is the critical first step in negotiating the difference of opinion?

A) Consult a professional ethicist to ensure that the steps of the process occur in full B) Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma C) Ensure that the attending physician or health care provider has written an order for an ethics consultation to support the ethics process D) List the ethical principles that inform the dilemma so negotiations agree on the language of the discussion Answer: B

Which is the best method of negotiating or processing difficult ethical situations?

A) Ethical issues arise between dissenting providers and can be best resolved by deference to an independent arbitrator such as chaplain B) Since ethical issues usually affect policy and procedure, a legal expert is the best consultant to help resolve disputes C) Institutional ethics committees help to ensure that all participants involved in the ethical dilemma get a fair hearing and an opportunity to express values, feelings, and opinions as a way to find consensus D) Medical experts are best able to resolve conflicts about outcome predictions Answer: C

When a nurse assesses a patient for pain and offers a plan to manage the pain, which principle is used to encourage the nurse to monitor the patient's response to the pain?

A) Fidelity B) Beneficence C) Non-Maleficence D) Respect for Autonomy Answer: A

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation?

A) Fidelity B) Beneficence C) Non-Maleficence D) Respect for Autonomy Answer: B

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable?

A) Nurses understand the principle of autonomy to guide respect for patient's self-worth B) Nurses have a scope of practice that encourages their presence during ethical discussions C) Nurses develop a relationship to the patient that is unique among all professional health care providers D) The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient care Answer: C

The philosophy sometimes called the ethics of care suggests that ethical dilemmas can best be solved by attention to which of the following?

A) Patients B) Relationships C) Ethical principles D) Code of ethics for nurses Answer: B

What is the best example of the nurse practicing patient advocacy?

A) Seek out the nursing supervisor in conflicting procedural situations B) Document all clinical changes in the medical record in a timely manner C) Work to understand the law as it applies to an error in following standards of care D) Assess the patient's point of view and prepare to articulate it Answer: D

Successful ethical discussion depends on people who has a clear sense of personal values. When a group of people share many of the same values, it may be possible to refer for guidance to philosophical principle of utilitarianism. This philosophy proposes which of the following?

A) The value of something is determined by its usefulness to society B) People's values are determined by religious leaders C) The decision to perform a liver transplant depends on a measure of the moral life that the patient has led so far D) The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician or health care provider. Answer: A

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following describes the role of the nurse in the resolution of ethical dilemmas?

A) To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations B) To await new clinical orders from the physician C) To limit discussions about ethical principals D) To allow the patient and the physician to resolve the dilemma without regard to personally held values or opinions regarding the ethical issues Answer: A

When an ethical dilemma occurs on your unit, can you resolve the dilemma by taking a vote?

A) Yes because ethics is essentially a democratic process, with all participate sharing an equal voice B) No because an ethical dilemma involves the resolution of conflicting values and principle rather than simply the identification of what people want to do C) Yes because ethical dilemmas otherwise take up time and energy that is better spent at the bedside performing direct patient care D) No because most ethical dilemmas are resolved by deferring to the medical director of the ethics department Answer: B

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health , safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you deleted all patient identifiers?

A) Yes because patient privacy would not be violated as long as the patient identifiers were removed B) Yes because respect for autonomy implies that you have the autonomy to decide what constitutes privacy C) No because, even though patient identifiers are removed, someone could identify the patient based on other comments that you make online about his or her condition and your place of work D) No because the principle of justice requires you to allocate resources fairly Answer: C

A woman who is a Jehovah's Witness has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood. What is the nurse's responsibility?

Abide by the husband's wishes and inform the health care provider

Center for Disease Control and Prevention

CDC

11. A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A) "CPOE reduces transcription errors." B) "CPOE reduces the time necessary for health care providers to write orders." C) "Health care providers can write orders from any computer that has Internet access." D) "CPOE reduces the time nurses use to communicate with health care providers."

CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly. Correct Answer(s): A

Emergency resuscitation given without client consent

CPR

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. What is the best nursing action to take first?

Call the nursing supervisor to discuss the situation

What is an appropriate way for a nurse to dispose of printed patient information? A) Rip several times and place in a standard trash can B) Place in the patient's paper-based chart C) Place in a secure canister marked for shredding D) Burn the documents

Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times. Correct Answer(s): C

A home health nurse notices significant bruising on a 2-year old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take?

Contact a child abuse hotline

An order to withhold treatment or resuscitation

DNR "do not resuscitate"

You are the night shift nurse and are caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the first nursing action to take?

Discuss the issues that concern the family with them

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications C) Your evaluation that the patient is "needy" D) How much the patient ate for breakfast E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients. Correct Answer(s): A, B, E

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws?

Emergency Medical Treatment and Active Labor Act (EMTALA)

Legislation requiring appropriate screening and stabilization in the emergency room

Emergency Medical Treatment and Active Labor Act (EMTALA)

The patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation?

Failure to document a change in assessment data Failure to notify a health care provider about a change in the patient's condition

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A) The nurses forgot to document on the pulmonary system. B) The nurses were charting by exception. C) The computer is not working correctly. D) The physician does not have authorization to view the nursing assessment.

Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits. Correct Answer(s): B

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A) HIPAA allows all hospital staff access to your medical record. B) HIPAA limits the information that is documented in your medical record. C) HIPAA provides you with greater control over your personal health care information. D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record. Correct Answer(s): C

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nursing manager because this action is a violation of which act?

Health Insurance Portability and Accountability Act (HIPAA)

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.

Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur. Correct Answer(s): B

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A) Documented medication given by another nursing student. B) Included the date and time of all entries in the chart. C) Stood with his back against the wall while documenting on the computer. D) Signed all documentation electronically.

Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed. Correct Answer(s): A

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.

Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record. Correct Answer(s): D

A patient asks for a copy of her medical record. The best response by the nurse is to: A) State that only her family may read the record. B) Indicate that she has the right to read her record. C) Tell her that she is not allowed to read her record. D) Explain that only health care workers have access to her record.

Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission. Correct Answer(s): B

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B) You need to use words the patients can understand when writing the directions. C) The form needs to be given to patients in a sealed envelope to protect their health information. D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.

Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability. Correct Answer(s): B

A nurse is caring for a patient who recently had coronary bypass surgery. Which are legal sources of standards of care the nurse uses to deliver safe health care?

Policies and procedures of the employing hospital State Nurse Practice Act Regulations identified in The Joint Commission's manual The American Nurses Association standards of nursing practice

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)?

Posting medical information about the patient on a message board in the patient's room

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits?

Surgeon

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse?

Taking or selling controlled substances Applying physical restraints without a written physician's order

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation?

The Good Samaritan laws, which grant immunity from suit if there is no gross negligence

A nurse is sued for failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit?

The person filing the lawsuit has the burden of proof. The plaintiff must prove that a breach in the prevailing standard of care caused an injury.

Which of the following charting entries is most accurate? A) Patient walked up and down hallway with assistance, tolerated well. B) Patient up, out of bed, walked down hallway and back to room, tolerated well. C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

The statement "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise" provides the most accurate, objective information for the chart. Correct Answer(s): D

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A) The patient has a defiant attitude and is demanding his test results. B) The patient appears to be upset with his nurse because he wants his test results immediately. C) The patient is demanding and complains frequently about his doctor. D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.

This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was demanding and frequently complaining is judgmental, and information in the medical record should be factual and nonjudgmental. Documenting that the patient appears upset needs to be more specific regarding the reason for the patient's concern. Correct Answer(s): D

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.

This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care. Correct Answer(s): B

Intentional threat to bring about harmful or offensive contact

assault

Intentional touching without consent

battery

Serious crime punishable by imprisonment or death

felony

A person's agreement to allow an invasive procedure with full disclosure of risks, benefits, alternatives, and consequences of refusal

informed consent

Negligence by a professional nurse or physician that causes injury to the client

malpractice

A system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs

risk management

A nurse is explaining to a patient how to follow infection control practices at home. During the discussion the nurse touches the patient on the shoulder. Explain which zone of touch the nurse should be practicing and what problems the action might cause.

see evolve

A civil wrong against a person or property, either intentional or unintentional

tort