Passpoint 6

A hospital uses the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? "Client reporting abdominal pain rated at 8/10." "Client is guarding her abdomen and occasionally moaning." "Client has a history of recent abdominal pain." "2 mg hydromorphone PO administered with good effect."

"Client reporting abdominal pain rated at 8/10." Explanation: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a report of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

Which client's response should the nurse address first? "My life is over if I gain weight." "I feel dizzy and light-headed when I get up." "I cannot eat because my teeth hurt." "I do not have the same energy that I used to have."

"I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. Answer one is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

An elderly client becomes confused and combative. The client's nurse receives an order for soft wrist restraints. When the client's family insists that he not be restrained, the nurse informs the family that the family must provide an around-the-clock attendant for the client to avoid use of restraints. The family spokesman replies, "You find the attendant; that is your responsibility." Which of the following would be the best response by the nurse? "It is your responsibility, as I have already stated to you." "The hospital cannot be responsible for the client's safety if you won't let us use restraints." "You are making the situation more difficult than it really is." "I recommend family members arrange to stay with the client."

"I recommend family members arrange to stay with the client." Explanation: Offering the family a solution to the situation is therapeutic and can advance rapport with the family. It can also facilitate the problem-solving process, which involves the client, family, and staff. Restating that finding an attendant is the family's responsibility and saying that family members are making the situation more difficult are confrontational approaches. Such statements don't increase rapport with the family or enhance problem-solving. The staff cannot renounce responsibility for the client if the family will not allow restraints.

A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session? "I will call my physician if my episiotomy hurts." "I should notify my physician if the vaginal discharge changes to a whitish color after 2 weeks." "I will call my physician if I notice redness, warmth, and pain in my breasts." "I should call my physician if I have a temperature of 99.2° F (37.3° C) for 24 hours or more."

"I will call my physician if I notice redness, warmth, and pain in my breasts." Explanation: Redness, warmth, and pain in the breasts indicate mastitis. Typically accompanied by fever, headache, and flulike symptoms, mastitis usually occurs 2 to 3 weeks after childbirth. The client should contact the physician if these symptoms occur. Episiotomy discomfort may persist for up to 6 weeks, depending on the extent of trauma. Lochia alba is normal at 2 weeks' postpartum. A temperature of 99.2° F (37.3° C) isn't significant. The client doesn't need to contact the physician if these signs or symptoms occur.

A female client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. She asks a male nurse if he is married or has a girlfriend. What is the best response by the nurse to maintain a therapeutic relationship? "Group therapy is not the appropriate time to discuss my relationships." "It sounds as though you are interested in developing a relationship with me." "Tell me how you knew that I was not married or had a girlfriend." "I'm curious about your question, but I want to know how you are feeling today."

"I'm curious about your question, but I want to know how you are feeling today." Explanation: Nurses must practice in a manner that is consistent with providing safe, competent, and ethical care. If the nurse shared personal information with the client, the nurse would have crossed the boundary of a therapeutic relationship and changed the focus of the discussion from a client focus to a social focus. It is very important in all areas of care, but especially in the mental health setting, that the relationship between the nurse and the client has very clear boundaries and is client focused. The other options are incorrect because they do not follow the principles of a therapeutic nurse-client relationship.

A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. He requests that his evaluation and counseling records be e-mailed to his Human Resources representative. How should the nurse respond? "We need to review our administrative policy with the agency director before we can release records." "It's best not to e-mail your personal records because doing so might jeopardize your right to privacy." "Think about whether you want us to release your entire counseling record to the company that employs you." "The treatment team must review disability-related records before we release them."

"It's best not to e-mail your personal records because doing so might jeopardize your right to privacy." Explanation: E-mailing personal health records to a client's place of employment increases the risk of breach of confidentiality. The nurse should make the client aware of this fact. Every health care agency has a policy and procedure related to release of client records; staff must be informed about the policy upon employment. Therefore, the nurse doesn't need to review the policy with the agency director when a client asks for his records to be released. It's inappropriate for a nurse to ask a client to think about his decision to release his records; doing so could make the client apprehensive. Review of a client's treatment goals and progress is an ongoing process; it isn't initiated when release of client records is requested.

A nurse is discussing wound care with a client. The client insists on taking a short video of the instruction by using the client's smart phone. What is the nurse's best response to the client? "After you record the video, are you going to post it to the internet?" "Let me check with the hospital policy regarding making a video." "I think we can find a video for you to view." "Let us make sure your name and face is in the video."

"Let me check with the hospital policy regarding making a video." Explanation: Use of technology and use of social media should be reviewed with the client. The institution may have a policy regarding what can and cannot be used.

A client is scheduled for a right lower lobectomy for lung cancer. During the admission assessment, the client asks for information about a living will and advance directive. The nurse knows that the client understands teaching about the living will and advanced directive when he says: "If I appoint a health care power of attorney, that person can override my wishes even if I'm still competent." "The advance directive allows me to state my health care wishes while I'm still able to do so." "The living will allows me to identify a person who can make health care decisions for me if I become too ill to make them myself." "I understand that in some states (provinces) a living will and health care power of attorney are the same."

"The advance directive allows me to state my health care wishes while I'm still able to do so." Explanation: The advance directive is a document that allows the client to give directions about future medical care or to designate another person to make medical decisions if and when the client loses decision-making capacity. The health care power of attorney is a legal document that enables the client to designate another person to act on the client's behalf if the client becomes disabled or incapacitated. The living will is a witnessed document indicating the client's desire to be allowed to die a natural death, rather than be kept alive by heroic life-sustaining measures. The living will applies to decisions that will be made after a terminally ill client is incompetent and has no reasonable possibility of recovery. The living will and health care power of attorney aren't the same.

A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond? "I will assign this client to another nurse." "I will help you take care of this client so you are confident with his care." "You seem worried about this assignment." "I will review blood and body fluid precautions with you."

"You seem worried about this assignment." Explanation: The RN assigning care should first give the UAP the opportunity to explore concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care.

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply. A client who just had coronary artery bypass graft (CABG) A client who needs initial admission assessment A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously A client who has C3 to C5 spine injury

A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously Explanation: An LPN/LVN can perform colostomy irrigation and administer subcutaneous injections. A client who just had CABG is unstable and needs to be monitored by an RN. The initial admission assessment should also be performed by an RN. C3 to C5 injury may cause respiratory compromise. Possible paralysis of diaphragm due to phrenic nerve involvement may occur. This client is unstable and should be assigned to an RN.

A nurse has been assigned to four clients. Which client should the nurse see first? A client with systemic lupus erythematosus (SLE) with malar rash on the face A client with rheumatoid arthritis who is receiving adalimumab for inflammation A client with Hodgkin's lymphoma complaining of fatigue and night sweats A client with hemophilia who is receiving acetylsalisylic acid (ASA) for joint pain

A client with hemophilia who is receiving acetylsalisylic acid (ASA) for joint pain Explanation: A client with hemophilia should be seen first because ASA will increase bleeding. It should not be given to a client with hemophilia. Malar rash or "butterfly" rash is usually seen in clients with SLE. Adalimumab is a tumor necrosis factor (TNF) inhibiting anti-inflammatory drug given to clients with rheumatoid arthritis. A client with Hodgkin's lymphoma is expected to have fatigue and night sweats.

A young client has been arrested for assault and battery. The client has been admitted to the forensic psychiatric facility for a pretrial evaluation. Which of the following client goals is most appropriate for the client? Accept responsibility for personal behavior. Participate in group therapy. Verbalize ways to express anger, such as playing age-appropriate video games. Avoid contact with others on the psychiatric forensic unit.

Accept responsibility for personal behavior. Explanation: Accepting responsibility indicates an insight into the reasons for his/her hospitalization. This client is not hospitalized to receive treatment but for an evaluation, so group therapies would not be a goal. Verbalizing ways to express anger, such as playing age-appropriate video games is not indicated, as video games could be a further stimulus for violent behavior. The client should be assessed before a treatment plan is begun. Avoiding contact with others on the psychiatric forensic unit is not indicated, and interaction would be useful for assessment. Further, the client has the right to interact with other clients on the unit.

A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when the vital signs suddenly change. The nurse checks the recovery room record (see chart). In addition to notifying the health care provider, what other action should the nurse take immediately? Administer dantrolene. Elevate the head of the bed 30 degrees. Administer a bolus of IV fluids. Insert an indwelling urinary catheter.

Administer dantrolene. Explanation: The client is demonstrating signs of malignant hyperthermia. Unless the body is cooled and the influx of calcium into the muscle cells is reversed, lethal cardiac arrhythmia and hypermetabolism occur. The client's body temperature can rise as high as 109° F (42.8° C) as body muscles contract. Dantrolene, an IV skeletal muscle relaxant, is used to reverse muscle rigidity. Elevating the head of the bed will not reverse the hyperthermia. Adding fluids and inserting an indwelling urinary catheter are not immediately beneficial steps in reversing the progression of malignant hyperthermia.

The nurse is reviewing the interventions listed in the plan of care for a child in vaso-occlusive crisis. Which intervention should the nurse implement first? Administering analgesics Monitoring fluid intake Encouraging activity as tolerated Administering antibiotics as prescribed

Administering analgesics Explanation: Pain management is a priority intervention when a client is in crisis. Analgesics are used to control pain. Hydration is essential to promote hemodilution and maintain electrolyte balance. Bed rest should be promoted to reduce oxygen utilization. Antibiotics will not be effective in resolving the vaso-occlusive crisis.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? Placing the client in a semi-Fowler's position Maintaining nothing-by-mouth (NPO) status Administering morphine I.V. as ordered Providing mouth care

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. What should the nurse do upon the client's arrival? Position the client in a supine position. Auscultate breath sounds every 4 hours. Monitor the vital signs every 4 hours. Admit the client to a quiet, darkened room.

Admit the client to a quiet, darkened room. Explanation: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.

A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation? Advise the nurse that he/she can be accused of battery. Inform the nurse that he/she can be accused of negligence. Ask the nurse if this is acceptable practice for this unit. Notify the licensing body of the nurse's behavior.

Advise the nurse that he/she can be accused of battery. Explanation: Battery is defined as an intentional and wrongful physical contact with a person that entails an injury or offensive touching. The other options are not correct because they do not describe the nurse's behavior.

A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an I.V. infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? Carefully titrating the oxytocin based on the client's pattern of labor Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes Allowing the client to ambulate as tolerated Helping the client use breathing exercises to manage her contractions

Allowing the client to ambulate as tolerated Explanation: Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include in the care plan.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? Acupuncture An exercise routine that includes range-of-motion (ROM) exercises Heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) Cold therapy

An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

The nurse is caring for an 8-year-old with a life-threatening illness. The parents do not speak the native language and want the child discharged so they can pursue alternative therapies that they believe will be less expensive. What is the most important action taken by the nurse to help the family and the child? Have a social worker help the family with the financial burden. Contact a clergy member to administer last rites to the child. Arrange to have a translator present when talking with the parents. Notify the healthcare provider that treatment will no longer be necessary.

Arrange to have a translator present when talking with the parents. Explanation: A translator is an immediate priority. No effective health teaching or social intervention will be effective until there is an established means of communication with the family.

When coaching a client to improve their health, which strategy is the most effective for the nurse to use to help clients take an active role in their health care? Ask clients to complete a questionnaire. Provide clients with written instructions. Ask clients for their views of their health and health care. Ask clients if they have any questions about their health.

Ask clients for their views of their health and health care. Explanation: One of the best strategies to help empower clients to manage their health is to ask them their view of situations and to respond to what they say. This technique acknowledges that clients' opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation, but alone it does not acknowledge their views

The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse? Ask team members to share information with the nurse instead of the family. Inform team members that only the parents should receive information. Review policies to see who should be informed of the child's treatment plans. Ask the family to identify a spokesperson to be the communicator with the team.

Ask the family to identify a spokesperson to be the communicator with the team. Explanation: In situations with large extended families where frequent updates are required or the state of the child is critical, it is imperative that a spokesperson be identified for receiving information and for disseminating the information to the extended family members.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change. Ask the assistant manager to develop a plan for the review and revision of client-education materials.

Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Explanation: Delegation must be clear and precise. The nurse-manager must assign responsibility, identify the task to be accomplished, explain the necessary outcomes, and define the time frame available to complete the work. The remaining options don't clearly define the work to be done, don't clearly assign responsibility or specify desired outcomes, or establish a time frame for completion of the task.

A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle? The right to die Advance directive Autonomy of the client Substituted judgment

Autonomy of the client Explanation: The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as he's competent and aware of the risks and complications associated with that refusal. The right to die is a difficult decision involving whether to initiate or withhold life-sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering with end-stage terminal illness. The client may have signed an advance directive, making his wishes known. An advance directive is a document that provides guidelines for starting or continuing life-sustaining medical care, generally for a client who has a terminal disease or disability and can't indicate his own wishes. Substituted judgment is an ethical principle used when a nurse makes a decision based on what's best for an incapacitated client.

An unlicensed nursing personnel (UAP) recorded a client's 0600 blood glucose level as 126 mg/dL (7 mmol/L) instead of 216 mg/dL (12 mmol/L). The UAP did not recognize the error until 0900 but reported it to the nurse right away. What should the nurse do first? Complete an incident report. Wait and observe the client for symptoms of hyperglycemia. Reprimand the UAP for the error. Call the health care provider (HCP) and complete an incident report.

Call the health care provider (HCP) and complete an incident report. Explanation: The error should be reported to the HCP promptly; the HCP may write additional prescriptions. The nurse should complete an incident report because a potentially dangerous event happened during the client's care. The nurse should observe the client for symptoms of hyperglycemia but first must call the HCP and complete an incident report. The UAP does not need to be reassigned for this error. The nurse does not need to reprimand the UAP for the error because the UAP already knows an error was made and has reported it to the nurse.

Which task may be safely delegated to a licensed practical nurse (LPN)? Teaching a client newly diagnosed with diabetes mellitus about insulin administration Admitting a client who underwent a thoracotomy to the nursing unit from the postanesthesia care unit Changing the dressing of a client who underwent surgery 2 days ago Administering an I.V. bolus dose of morphine sulfate to a client experiencing incisional pain

Changing the dressing of a client who underwent surgery 2 days ago Explanation: The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the postanesthesia care unit is beyond the scope of practice for an LPN; LPNs aren't permitted to give I.V. push drugs.

A nurse is working day shift on a surgical unit at a hospital that was recently unionized and has insufficient staffing to provide competent care to the clients. What should the nurse do? Select all that apply. Ask the supervisor to be placed on a different unit for the shift. Complete an unsafe staffing form and provide care as safely as possible. File a written protest to the administration, but accept the assignment. Tell the clients about the staffing issue while trying to provide safe care. Refuse the unsafe client assignment and leave the surgical unit.

Complete an unsafe staffing form and provide care as safely as possible. File a written protest to the administration, but accept the assignment. Explanation: The nurse must accept the assignment or be liable for negligence and abandonment. The nurse should fill out an unsafe staffing form as soon as possible as this may be evidence to provide protection in the case of a medical error during the shift. Refusing the assignment is illegal and abandonment. Verbal notification can be provided but is not the best action as there is not a record of the conversation if a problem occurs. Clients should never know that staffing is unsafe as this will create unnecessary anxiety or stress for the client.

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day? Complete regular admission procedures. Schedule the client for screening tests. Prepare for long-term care needs. Provide detailed information on the procedure.

Complete regular admission procedures. Explanation: Clients entering the hospital setting for outpatient surgery have regular admission procedures conducted by the nurse. Scheduling of screening tests and initial teaching is completed in the days prior to the surgery. Same-day surgery and discharge may require community-based follow-up, but it generally does not require long-term care. Detailed information on the procedure will be provided by the physician performing the procedure.

A nurse administering medications is unfamiliar with ropinirole, the medication ordered for a client with Parkinson's disease. What actions should the nurse perform prior to administering the medication? Select all that apply. Check the client's medication administration record for clarification of the medication. Contact the pharmacist for information about this medication. Refer to a reliable nursing drug handbook to verify the action, usual dosage, adverse effects, and nursing considerations for this medication. Ask an experienced nurse on the unit who is familiar with the medication for necessary dosing considerations. Check with the client regarding the medication, verifying its accuracy.

Contact the pharmacist for information about this medication. Refer to a reliable nursing drug handbook to verify the action, usual dosage, adverse effects, and nursing considerations for this medication. Explanation: A nurse must be knowledgeable about a medication before administering it to a client. A reliable nursing drug handbook will include information about the drug's expected action, usual dosage, adverse effects, and nursing considerations. It is also acceptable to consult the pharmacist. The client's medication administration record will not include this information. It is also not necessarily reliable to refer to the client regarding the medication. While many clients are very knowledgeable, you should not assume this.

A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used. 1 Contact the security department. 2 Obtain an ECG. 3 Obtain a urine sample. 4 Initiate a referral to obtain drug rehabilitation counseling.

Contact the security department. Obtain an ECG. Obtain a urine sample. Initiate a referral to obtain drug rehabilitation counseling. Explanation: The nurse should first provide for safety of the client and the staff by requesting assistance from the security department. Next, the nurse should obtain an ECG because the client reports having chest pain. The nurse should then obtain a urine sample to identify if the client has been using illegal drugs. When the client is stabilized, the nurse can develop a care plan that includes treatment goals to support the respiratory and cardiovascular functions and enhance clearance of the agent and initiate a referral for treatment where access to the drug is eliminated and drug rehabilitation is provided as part of therapeutic management of clients with substance abuse and/or a drug overdose.

The nurse is caring for an eight-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? Diluting the chemicals Applying sterile dressings Applying topical antibiotics Debriding and grafting the burns

Diluting the chemicals Explanation: Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which of the following is the best action for the first nurse to take? Tell the client not to meet the nurse socially. Report the conversation to the nurse manager. Encourage the interaction with the client after discharge. Discuss the conversation directly with the other nurse.

Discuss the conversation directly with the other nurse. Explanation: Planning to meet a client for a social event while the client is still hospitalized could blur the boundaries of the therapeutic relationship. This could result in an unhealthy outcome for the client. The nurse should take the second nurse aside and point out that the behavior is inappropriate and not in the client's best interest. The other options do not demonstrate behavior that is consistent with the therapeutic nurse-client relationship.

A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first? Position woman on her left side, and administer oxygen via face mask. Document findings on the woman's medical record, and continue to monitor labor progress. Perform vaginal exam to rule out umbilical cord prolapse. Notify the health care provider (HCP) immediately, and prepare for emergency caesarean section.

Document findings on the woman's medical record, and continue to monitor labor progress. Explanation: The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or oxygen, as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean section.

In preparing for a client's admission to the unit, what is the nurse's responsibility? Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff. Ensuring that all staff caring for the client are in the client's room when he or she arrives at the unit. Greeting the client in the emergency department or admitting office. Delegating the admission assessment to a nursing assistant.

Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff. Explanation: Although the nurse might delegate most activities in preparing the room for admission, it is the nurse's responsibility to ensure that the other personnel complete the preparation. It is not necessary for all care staff to be present when the client arrives and, in fact, it might be quite overwhelming to the client to have them all present. The nurse will greet the client and family members upon their arrival to the unit. An admission assessment is the responsibility of the nurse, not a nursing assistant, who is not educated to perform this skill.

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member? Social worker Staff nurse Clinical educator Enterostomal nurse

Enterostomal nurse Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care? Good Samaritan laws are designed to protect the caregiver in emergency situations. Negligence is intentional failure to act responsibly or deliberate omission of a professional act. Malpractice is failure to perform professional duties that result in client injury. Scope of practice involves general guidelines that define nursing.

Good Samaritan laws are designed to protect the caregiver in emergency situations. Explanation: Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct.

The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. What should the unit director do? Select all that apply. Identify the problem at a staff meeting without placing blame on any individual or group. Ask the unit staff to develop a plan that they think will work for the unit members. Ask an experienced nurse to spend time reorienting newer staff members. Collaborate with the staff development educator to develop a plan. Ask the neonatologist to give a presentation about assessing newborns.

Identify the problem at a staff meeting without placing blame on any individual or group. Ask the unit staff to develop a plan that they think will work for the unit members. Collaborate with the staff development educator to develop a plan. Explanation: All areas concerned with the safety and quality of care need to participate in the decision-making process and arrive at a plan that will meet the needs of the clients on the neonatal care unit. Identifying the problem at a staff meeting is an ideal forum to bring up the need for improvement and education. The staff is an integral part of the development team. The staff educator is an important member of the team and is responsible for orienting new nurses to the unit. Asking an experienced staff member to spend time in reorienting staff members is difficult to do as the nurses have their own clients to care for. Although the unit director can obtain additional information from the health care providers (HCPs) about the problem, the nursing staff has responsibility for assuring that they are providing safe and high quality care.

A client with a history of osteoarthritis is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes? Coordinating activities in the morning so that the client can rest in the afternoon and evening Coordinating all activities in the afternoon so that the client is tired at bedtime. Alternating periods of activity with periods of rest to optimize client participation Including the client in developing a care plan that works toward meeting discharge goals

Including the client in developing a care plan that works toward meeting discharge goals Explanation: Involving the client in the care plan development optimizes client outcomes; alternating periods of activity and rest helps optimize participation. Coordinating all activities in the morning or afternoon doesn't necessarily optimize client participation.

A client requests his medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that he can go to sleep earlier. Which type of nursing intervention is required? Intradependent Interdependent Dependent Independent

Independent Explanation: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already ordered drug on time is a dependent intervention. There's no such thing as an intradependent nursing intervention.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: Limiting abbreviations to those approved for use by the institution. Using only abbreviations whose meaning is self-evident to an educated health professional. Ensuring the abbreviations are understandable to clients who may seek access to their health records. Using those abbreviations defined in full at another location in the client's chart.

Limiting abbreviations to those approved for use by the institution. Explanation: In addition to avoiding abbreviations prohibited by the Joint Commission, it is important to limit the use of abbreviations to those recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

Which of the following involves charting information about the client and client care in chronological order? Focus charting. SOAP charting. Narrative charting. PIE charting.

Narrative charting. Explanation: Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? Narrative notes. SOAP notes. Focus charting. Charting by exception.

Narrative notes. Explanation: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take? State that the physician will be a witness. Arrange for other colleagues to sign as a witness. Note that the nurse caring for the client cannot be a witness. Inform the physician about the living will.

Note that the nurse caring for the client cannot be a witness. Explanation: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining. Calling for a physician or asking another colleague to sign is an inappropriate action.

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take? Refuse to float to the ICU. Notify the nursing supervisor that she feels unqualified and untrained for the assignment. Report to the ICU and accept a total client assignment; ask the nurses for assistance when necessary. Report to the ICU, tell the ICU nurses she has never worked in the ICU, and let the nurses decide what tasks she can perform.

Notify the nursing supervisor that she feels unqualified and untrained for the assignment. Explanation: The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained to float in the ICU. The nursing supervisor can advise the pediatric nurse about tasks she is qualified to perform in the ICU without jeopardizing her nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable way for managing resources. Having the ICU nurses determine what tasks the pediatric nurse can perform makes the ICU nurses responsible for the pediatirc nurse's performance. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never accept responsibility for a total client care assignment if she doesn't have the skills to plan and deliver care.

A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-hour period. What is the priority nursing action? Eliminate the liquids between meal times. Divide the fluids equally among the three 8-hour nursing shifts. Notify the dietary department of a clear fluids order. Offer the client proportioned fluids in the day and less during the night.

Offer the client proportioned fluids in the day and less during the night. Explanation: The client and nurse should make a fluid schedule that takes into consideration factors such as periods of wakefulness, number of meals, oral medications, and personal preferences. Avoiding night fluids will decrease risk for aspiration. Other answers do not provide the client with autonomy of care, and good sleep patterns are essential for overall heal

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? Protects the client's right to self-determination in health care decision making. Helps the client refuse treatment that he or she does not wish to undergo. Helps the client to make a living will regarding future health care required. Provides the client with in-depth knowledge about the treatment options available.

Protects the client's right to self-determination in health care decision making. Explanation: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? Recommending that the client discontinue chemotherapy Providing a solution of viscous lidocaine for use as a mouth rinse Monitoring the client's platelet and leukocyte counts Checking regularly for signs and symptoms of stomatitis

Providing a solution of viscous lidocaine for use as a mouth rinse Explanation: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which of the following best describes why the nurse is asking questions about the family's birth plan? Establishing rapport with the family Acting as an advocate for the family Attempting to correct any misinformation the family may have received Recognizing the family as active participants in their care

Recognizing the family as active participants in their care Explanation: The nurse recognizes the family as active participants in their care by discussing and inquiring about their birth plans, fostering a collaborative relationship with the family. After acknowledging the family as active participants, the nurse is then able to advocate for the family throughout the labor and birth experience. Considering principles of family-centered maternity and newborn care, nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse's role to guide and support choices rather than direct or correct.

A 17-year-old unmarried primigravida at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do? Instruct the client in methods for low-cost, highly nutritious meal preparation. Determine whether the client qualifies for local assistance programs. Refer the client to a social worker for enrollment in a food assistance program. Ask the client if she has a job and the amount of income earned.

Refer the client to a social worker for enrollment in a food assistance program. Explanation: The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program. Instructing the client in low-cost, highly nutritious meal preparation will not meet the client's needs for additional funds for food. Determining whether the client qualifies for government assistance is part of the role of the social worker, not the nurse. Asking the client if she has a job and the amount of income earned is not within the role of the nurse. The social worker can determine whether the family income guidelines are met for assistance.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? Registered nurse with one year of experience Licensed practical nurse (LPN) with five years of experience Nursing assistant with 15 years of experience Charge nurse with 10 years of experience

Registered nurse with one year of experience Explanation: Because this client requires frequent neurovascular assessments, a registered nurse should receive him. Although experienced and able to collect data, an LPN doesn't have the education to assess this client. The nursing assistant lacks the necessary assessment skills. The charge nurse needs to be available to direct the care of other clients.

A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching? Empty the bile bag daily. Breathe deeply into a paper bag when nauseated. Keep adhesive dressings in place for 6 weeks. Report bile-colored drainage from any incision.

Report bile-colored drainage from any incision. Explanation: There should be no bile-colored drainage coming from any of the incisions postoperatively. A laparoscopic cholecystectomy does not involve a bile bag. Breathing deeply into a paper bag will prevent a person from passing out due to hyperventilation; it does not alleviate nausea. If the adhesive dressings have not already fallen off, they are removed by the surgeon in 7 to 10 days, not 6 weeks.

An older adult client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I'll blow him away with my shotgun. He has never respected my property line, and I've had it!" Which action should the nurse take? Observe the client more closely, but do not report his threat since he will likely not be able to follow through with it because of his dementia. Report the comment to the client's daughter so she can observe him more closely, but refrain from telling the neighbor due to privacy regulations. Report the comment to the neighbor, the intended victim, but refrain from telling the daughter since she will just worry about actions of her father she cannot control. Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act.

Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. Explanation: The neighbor could be harmed as well as the daughter if she should try to stop her father from using the gun, so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so and to document it can result in civil penalties. The client's early dementia would likely not prevent him from carrying through his threat.

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners? Respiratory therapist. Physical therapist. Physician. Occupational therapist.

Respiratory therapist. Explanation: A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in forgoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely to provide needed interventions at this time.

The charge nurse is preparing for the day shift on the labor and birth unit. Which would be included in the responsibilities for this position? Select all that apply. Review the current status of each labor patient with the primary nurse. Admit the new labor patient sent from the triage area. Complete the work of the nurse who had to leave 30 minutes early. Follow up with the primary nurse after a birth. Complete report of unit with the oncoming charge nurse.

Review the current status of each labor patient with the primary nurse. Follow up with the primary nurse after a birth. Complete report of unit with the oncoming charge nurse. Explanation: In most settings, the charge nurse coordinates and directs the activities of the unit. Prior to the change of shift, the nurse will review and update the status of each of the laboring clients on the unit to include any difficulties or unusual situations that may be occurring with each of them, including following up with a primary nurse after a birth. A change-of-shift report with the oncoming charge nurse is among the last activities completed before ending the shift. Activities such as admitting a client in labor and completing the nursing responsibilities of the nurse who had to leave 30 minutes early can be delegated to staff members. In an emergency, the charge nurse could assume responsibility for client care.

The health care provider (HCP) has prescribed a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical-surgical floor, but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse's most appropriate response? Send the client to the oncology floor for administration of the medication. Ask a nurse from the oncology floor to come to the client and administer the medication. Ask another nurse to help mix the chemotherapy agent. Ask the pharmacy to mix the chemotherapy agent and administer it.

Send the client to the oncology floor for administration of the medication. Explanation: The nurse should call the oncology unit to institute a transfer. The nurse handling chemotherapy agents should be specially trained. It is an unwise use of nursing resources to send a nurse from one unit to administer medications to a client on another unit. It is better to centralize and send the client who needs chemotherapy to one unit. Even if the pharmacy mixes the agent, the drug must be administered by a specially trained nurse.

A nurse meets his/her neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Post accolades to the nurse at the nurses' station. Send the colleague an anonymous card. Share the feedback with the nursing colleague directly. It is a breach of confidentiality to share this information with the colleague.

Share the feedback with the nursing colleague directly. Explanation: It is not a breach of confidentiality for the nurse to share the feedback with the colleague, and by doing so the nurse will recognize the value of the colleague's professional efforts and accomplishments. It is not appropriate to place an announcement at the nurses' station or to send an anonymous card. It is crucial that nurses uphold the standards for professional practice and consider the American Nurses Association (Canadian Nurses' Association) Code of Ethics, in particular surrounding the principles of preserving dignity and maintaining privacy and confidentiality.

What are important nursing responsibilities when a referral to other health team members has been made for a client? Ensuring that the physician reports the level of functioning of the client Recommending that each health team member independently completes his or her own assessment and then consults with each other Recommending that each member read the history and nurse's notes to understand the client's progress Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living

Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living Explanation: Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.

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? 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. Contact the hospital chaplain to sign the consent on the client's behalf.

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

The nurse notes that which statement concerning informed consent is true? Minors may give informed consent to all medical and nursing procedures without consent of the parent(s). The professional nurse and physician must each obtain informed consent because the practice of medicine and of nursing are two distinct entities. The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. Mentally incompetent clients may legally give informed consent only if they are hospitalized under a mental health regulatory law.

The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. Explanation: Before giving informed consent, the physician performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. A professional nurse involved in the informed consent process witnesses the consent and doesn't actually obtain the consent. The physician is responsible for obtaining consent. Only a minor who is married or emancipated may give informed consent. A client must be mentally competent to legally give informed consent for procedures.

A nurse administers medications to the wrong client in a hospital. The client has an anaphylactic reaction to one of the medications and expires. What legal actions against the nurse can the family pursue? Select all that apply. There are no legal consequences with the common error. The family can open a legal claim for malpractice against the nurse. The family can open a legal claim for malpractice against the hospital. The family can seek a fair settlement outside the courtroom. The nurse can resign from the hospital and no further legal action will occur.

The family can open a legal claim for malpractice against the nurse. The family can open a legal claim for malpractice against the hospital. The family can seek a fair settlement outside the courtroom. Explanation: The family can open a legal claim for malpractice with the nurse and with the hospital. The family can seek a settlement outside the courtroom. There are legal consequences with a sentinel event. Medication safety errors are not common. The nurse can resign from the hospital but further legal action can be pursued against the nurse.

A graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first? The newly admitted client with acute abdominal pain The client who underwent surgery 3 days ago and who now requires a dressing change The client receiving continuous tube feedings who needs the tube-feeding residual checked The sleeping client who received pain medication 1 hour ago

The newly admitted client with acute abdominal pain Explanation: The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings. These tasks are of equal importance. They should assess the sleeping client who received pain medication 1 hour ago last because he just received relief from his pain and is able to sleep.

Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. The nurses have given multiple opportunities for potential participants to ask questions and have been following the informed consent process systematically. The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.

The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. Explanation: The principle of nonmaleficence dictates that nurses avoid causing harm. In this study, this may appear in the form of taking measures to ensure that the intervention will not cause more harm than good. The principle of justice addresses the distribution of risks and benefits and the informed consent process demonstrates that autonomy is being protected. Preliminary indications of the therapeutic value of the intervention show a respect for the principle of beneficence.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply. The nurse was correct to call a code blue. The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. She must have read the chart incorrectly. The code should have continued.

The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. Explanation: By initiating a code blue, the nurse didn't follow the client's advance directive and DNR order. The physician was correct to follow the client's wishes and stop resuscitation efforts. The physician had the authority to stop the code.

A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client's face. How will the nurse precede? Call the healthcare provider immediately Securely tape the tube in place Note the findings on the client's flow sheet Verify placement of the tube

Verify placement of the tube Explanation: The NG tube placement should be verified prior to re-taping the NG tube; the other options require verification of the NG tube placement first and the healthcare provider will need to know.

The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used. 1 Verify the client has signed an informed consent. 2 Position the client in a side-lying position. 3 Clean the skin with an antiseptic solution. 4 Apply ice to the biopsy site.

Verify the client has signed an informed consent. Position the client in a side-lying position. Clean the skin with an antiseptic solution. Apply ice to the biopsy site. Explanation: First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then, the nurse should clean the skin site and surrounding area with an antiseptic solution before the health care provider (HCP) numbs the site and collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.

A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is prescribed, but the mother will not sign the consent until the father arrives to give permission. What should the nurse do? Report this to the social worker. Call the regional protective services for children. Wait until the father arrives. Inform the health care provider (HCP) that the mother has refused to have the procedure.

Wait until the father arrives. Explanation: In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission. It is not necessary to contact the social worker at this point. The client has not refused the procedure, so it is premature to contact the HCP. This is not a situation of suspected child abuse.

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant? Suggesting to the infant's caregiver to continue to try to feed the infant even when the infant is crying. Weighing the unclothed infant at the same time every day. Reporting the caregiver to social services for suspected abuse. Requiring the caregiver to attend a community support group prior to discharge.

Weighing the unclothed infant at the same time every day. Explanation: Daily weights are an appropriate intervention for an infant with failure to thrive. It would be inappropriate for the nurse to encourage the caregiver to continue to try to feed the infant when crying because the infant may develop further aversion to eating. It is also inappropriate to assume that abuse has taken place; there is no information in the stem to suggest this. The caregiver would benefit from a community support group; however, the nurse cannot require the caregiver to attend a community support group prior to discharge.

Under which circumstance may a nurse communicate medical information without the client's consent? when certifying the client's absence from work when requested by the client's family When treating the client with a sexually transmitted disease when prescribed by another health care provider (HCP)

When treating the client with a sexually transmitted disease Explanation: Sexually transmitted infections are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency and to otherwise maintain the client's confidentiality. The client's family cannot request release of medical information without the client's consent. A HCP's prescription is not a substitute for a client's consent to release medical information in the absence of a communicable disease.

A nurse is obtaining consent for a bone marrow aspiration. Which actions should the nurse take? Select all that apply. Witness the client signing the consent form. Evaluate that the client understands the procedure. Explain the risks of the procedure to the client. Verify that the client is signing the consent form of his or her own free will. Determine that the client understands postprocedure care.

Witness the client signing the consent form. Evaluate that the client understands the procedure. Verify that the client is signing the consent form of his or her own free will. Determine that the client understands postprocedure care. Explanation: The nurse can serve as a witness for consent for procedures. The nurse also ascertains whether the client has an understanding that is consistent with the procedure listed on the form, determines that the client is signing the consent of his or her own free will, and determines that the client understands post-procedure care. The nurse's role does not include explaining the risks of the procedure; that responsibility belongs to the person who is to perform the procedure, such as the health care provider (HCP).

The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do? Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller. Repeat the results to the caller from the laboratory, write the results on scrap paper, and then transfer the results to the medical record. Indicate to the caller that the nurse cannot receive results from lab tests over the telephone and ask the lab to bring the written results to the nurses' station. Request that the laboratory send the results by e-mail to transfer to the client's medical record.

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller. Explanation: To assure client safety, the nurse first writes the results on the chart, then reads them back to the caller and waits for the caller to confirm that the nurse has understood the results. The nurse may receive results by telephone; and although electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nurses station.

Which client should the nurse assess first? a client being treated for chronic stable angina who reports a recent increase in chest pain frequency a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week a client with chronic hypertension whose blood pressure today is 182/98 mm Hg

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Explanation: A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy? a compromised skin graft. a malignant tumor. pneumonia. hyperthermia.

a compromised skin graft. Explanation: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks the client if he/she has an advanced directive. The client asks for an explanation of advanced directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is: a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. a legal document, made by the client when he/she is healthy, that directs others to follow the client's wishes if he/she is incapacitated legal document that is commonly referred to as a living will and recognized in all North America. also known as a health care proxy, where the client indicates a person or persons to make health care decisions for them if they become incapacitated.

a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. Explanation: A facility refers to an advance directive, a document the client writes or completes, to provide care at a time when the client cannot make his/her own choices. The living will and health care proxy are both examples of advance directives. A living will is a document which a competent adult prepares and which provides direction regarding medical care if the client becomes incapacitated. Health care proxy is an authorization enabling any competent individual to designate someone else to exercise decision-making authority on the individual's behalf under specific circumstances.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? a woman who is 5 months pregnant with no apparent injuries a middle-aged man with no injuries who has rapid respirations and coughs a 10-year-old with a simple fracture of the humerus who is in severe pain a 20-year-old with first-degree burns on her hands and forearms

a middle-aged man with no injuries who has rapid respirations and coughs Explanation: The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous childbirth. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client? a nurse who was reassigned from another ward at the beginning of the shift a nurse whose patient with asthma has decreasing oxygen saturation levels a nurse caring for a client who is paralyzed and has no visiting family a nurse who is about to start a complicated wet-to-damp dressing change

a nurse who was reassigned from another ward at the beginning of the shift Explanation: The nurse's work load would be low because she was reassigned to the ward at the beginning of the shift. The client with asthma requires constant monitoring by the nurse until the situation is resolved. Simple tasks and procedures are commonly more time-consuming when clients with paralysis are involved because these clients can't directly aid in their own care. Additional time must also be allotted for the nurse about to undertake a complicated procedure, such as a wet-to-damp dressing change.

The following pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first? a crying 3-year-old whose parent is holding a cloth on the child's head covering a scalp laceration a lethargic 15-month-old with pink cheeks whose parent reported temperature of 38.4°C (101.2°F) a quiet 2-year-old with nasal flaring who is sitting in a tripod position a pale 6-month-old with a frequent cough and audible wheezing

a quiet 2-year-old with nasal flaring who is sitting in a tripod position Explanation: The nurse identifies the nasal flaring and particularly the tripod position as indications of respiratory distress. This pediatric client needs rapid assessment and intervention and will be seen first. The other pediatric clients are not in immediate danger and will be seen as soon as possible by a healthcare professional.

Which family should the nurse determine as most in need of follow-up? a single mother with a 7-month-old child whose immunizations are delayed a two-parent family whose 3-year-old has a fractured leg from an automobile accident a single parent with a toddler who has third-degree burns over 20% of the body a two-parent family with a foster child who has a history of caustic liquid ingestion

a single parent with a toddler who has third-degree burns over 20% of the body Explanation: Toddlers receive burns usually as the result of not being closely supervised. Toddlers are very inquisitive and need constant supervision; therefore, close follow-up is necessary. In addition, the child probably will need some type of wound care requiring involvement of the parent and possibly others. The amount of support available to the single parent of the 7-month-old child is not known. Although immunization schedules need to be adhered to, it is very possible for a 7-month-old to be delayed in receiving immunizations because of illness or other conflicts. An automobile accident can happen to anyone and does not indicate a lack of safety or supervision. A history of caustic liquid ingestion in a foster child may have been from a time before the child began living with the foster parents; it does not indicate a lack of safety or supervision.

The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately? a woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine a woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing two to three hyperglycemic episodes weekly a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria a primigravida at 15 weeks' gestation who reports she has not felt fetal movement

a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria Explanation: The nurse should refer the preeclamptic client with 3+ proteinuria to an HCP. The 3+ urine is significant, indicating there is much protein circulating. The woman who is 37 weeks' gestation with insulin-dependent diabetes and who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tablets until she can obtain an appointment with the care provider. The client at 10 weeks' gestation with nausea and vomiting and +1 ketones should also be seen by an HCP, but at this point, although this client is uncomfortable, her life is not in danger. The 15-week client would not be expected to feel her baby move this soon in the pregnancy, and this would not be considered a problem that requires immediate referral to an HCP.

The registered nurse (RN) is working in a 30-bed long-term care facility on the night shift and is working with two licensed practical/vocational nurses (LPN/VN) and four certified nursing assistants (CNA). Which primary care provider and nursing orders are most appropriately delegated to the LPN/VN? Select all that apply. obtaining a stool culture performing catheter care checking a client for liquid stools every 1 hour reorienting the client to person, place, and time administering oral medications obtaining a urine culture

administering oral medications Explanation: The licensed nurse (LPN/VN) can perform any of these orders because the nurse has the education and license needed to perform the orders. The licensed nurse (LPN/VN) must administer the oral medications because of the education and license needed, and all the other orders can be delegated to the CNA.

Which statement indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? The client: will avoid direct contact with family and friends. can state actions to reduce pain. will use oxygen via a nasal cannula at 5 L/min. agrees to call the health care provider (HCP) if dyspnea on exertion increases.

agrees to call the health care provider (HCP) if dyspnea on exertion increases. Explanation: Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the client should notify the HCP. It is not necessary to avoid being around others. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/min) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

A client who is taking olanzapine states he is being poisoned and refuses to take his scheduled medication. The nurse states, "If you do not take your medication, you will be put into seclusion." The nurse's statement is an example of which legal concept? assault battery malpractice invasion of privacy

assault Explanation: The nurse's statement exemplifies assault, which is the threat of being touched in an offensive way without consent. Battery is touching another person without consent. Malpractice is care below the standard of care that results in injury. Invasion of privacy is a violation of a person's right to be left alone.

The nurse is teaching the client to self-administer insulin. Learning goals most likely will be attained when they are established by the: nurse and client because both need to be responsible for teaching. health care provider and client because the health care provider is the manager of care and the client is the main participant. client because the client is best able to identify his or her own needs and how to meet those needs. client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team.

client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team. Explanation: Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse, pharmacist, and health care provider. Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse, pharmacist, and health care provider help the client arrive at his or her own perception of the need or reason to learn.

A child with spastic cerebral palsy is to begin botulinum toxin type A injections. Which treatment goals should the health care team set for the child related to botulinum toxin? Select all that apply. improved nutritional status decreased pain from spasticity improved motor function enhanced self-esteem reduced caregiver strain decreased speech impediments

decreased pain from spasticity improved motor function enhanced self-esteem reduced caregiver strain Explanation: Botulinum toxin injections can be used to improve many aspects of quality of life for the child with cerebral palsy. The injections can help decrease pain from spasticity. Injections improve motor status by reducing rigidity and allowing for more effective physical therapy to improve range of motion. Decreased spasms enhance self-esteem. Improved motor status facilitates the ability to provide some aspects of care, especially transfers. Botulinum does not significantly affect nutritional status or speech.

A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time? ability to care for self feelings of anxiety barriers to effective communication experiences of powerlessness

feelings of anxiety Explanation: Anxiety is the top priority at this time. The client is exhibiting behavior that is indicative of anxiety, including restlessness, irritability, rapid speech, and inability to complete tasks. The other aspects of the nursing assessment are significant, but are not the top priority.

The nurse is serving on the Quality Improvement Committee for the maternity unit. Quality improvement projects for this unit impacting safety and quality of care include which projects? Select all that apply. use of recycling bins on the unit infant identification system sibling and family visitation policies postpartum discharge instructions rooming in guidelines

infant identification system sibling and family visitation policies postpartum discharge instructions rooming in guidelines Explanation: The use of recycling bins on the unit does not impact safety or contribute to the quality of care. The infant identification system is a safety practice. Nursing influences the type of system used and how monitoring and identification occur, which improves the quality of care. The sibling and family visitation policy can be an excellent project. Sibling policies regarding visitation can influence safety (safety of mother and infant by keeping children with colds/flus, infections away from the obstetrics unit). Nursing influences development of the policy utilized and implemented on a daily basis. Postpartum instructions represent an area where the skill level, quality, and quantity of instruction represent nursing contributions to care. The ability for a family to remain together during a hospital stay is important to families. The quality of the obstetrical experience can be enhanced or determined to be negative by this particular policy, one that is often looked at by these committees.

After the nurse informs the surgeon that a chest tube is malfunctioning, the health care provider asks the nurse to reposition the tube and obtain a chest radiograph. The nurse should: inform the surgeon this is not within the safe scope of practice. report the surgeon to the Ethics Committee. report the surgeon to the nursing supervisor. follow the prescription as requested by the surgeon.

inform the surgeon this is not within the safe scope of practice. Explanation: Initially, the nurse needs to inform the surgeon that the task is outside the scope of nursing practice. If the surgeon still requests the activity, the nurse should refuse to perform the task and should follow the chain of communication for reporting unsafe practice according to the facility's policy. The nurse must not comply with any prescription that goes beyond the scope of nursing practice.

hyperbaric oxygen therapy

involves breathing pure oxygen in a special chamber that allows air pressure to be raised up to three times higher than normal

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff? proper documentation of a verbal order from a physician policy changes in the administration of opioids new education materials for the management of diabetes logging off a computer containing client information

logging off a computer containing client information Explanation: All members of the healthcare team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and client education aren't within the scope of practice of the clerical support staff.

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3cm, 100% effaced and station -1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. The priority action by the nurse is to: reassure the patient and assist with nonpharmacologic pain interventions. assess the intensity of contractions and determine if she would like an epidural. notify the provider of the pain and request an assessment for potential abruption. perform a vaginal examination and coach the woman with breathing exercises for pain control.

notify the provider of the pain and request an assessment for potential abruption. Explanation: The woman is at risk for placental abruption due to her recent car accident. Symptoms of a placental abruption include unrelenting pain and a rigid boardlike abdomen. She may or may not have vaginal bleeding. In contrast, labor contractions are intermittent. The priority action by the nurse should be to ensure that this client is further evaluated by her HCP. Subsequent actions could include assisting with pain control measures, assessing contractions, and checking cervical dilation.

A primigravid client at about 36 weeks' gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which person must the nurse notify? nursing unit manager so appropriate agencies can be notified head of the hospital's security department chaplain in case the fetus dies in utero primary care provider who will attend the birth of the infant

primary care provider who will attend the birth of the infant Explanation: The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth restriction. Therefore, the nurse must notify the primary care provider of the client's cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the client's care. The nurse manager may become involved depending on unit policies when information about the cocaine use is shared with other social service, legal, or health agencies that become involved with the client's long-term care, but this is not necessary until the baby is born. The head of the hospital's security department does not need to be notified unless there is a suspicion of drug dealing taking place. The chaplain need not be notified at this time. If the fetus dies in utero and the client requests a chaplain, then the nurse can contact one.

The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? policies from other hospitals data from retrospective studies published national standards expert opinions

published national standards Explanation: Published national standards are based on the best evidence and when available should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available.

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to: immediately remind the night-shift nurses of the daily calibrations. arrange a meeting of the day-shift and night-shift nurses. review the capillary glucose monitoring calibration log book. counsel the night charge nurse about the discrepancy.

review the capillary glucose monitoring calibration log book. Explanation: When dealing with complaints, a nurse-manager should always gather data before taking action. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data relative to the complaint.

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications that the client's relative, spouse or legal guardian was present

that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications Explanation: The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present.

A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN? the 2-year-old child who has started eating soft, solid foods following a tonsillectomy a 12-month-old infant who has a white blood cell (WBC) count of 34/μl and a fever a 17-month-old infant with a contusion as a result of a motor vehicle accident 4 hours earlier a 22-month-old infant with type 1 diabetes who has a blood glucose level of 277 mg/dl (15.37 mmol/L).

the 2-year-old child who has started eating soft, solid foods following a tonsillectomy Explanation: The nurse can delegate care of the child who had the tonsillectomy to the LPN because that child is stable and likely preparing for discharge. The infant with a WBC count of 34/μl and fever requires close monitoring for additional signs of infection. Infection could lead to sepsis or septic shock. Although the infant with contusions from the motor vehicle accident may be stable, children sometimes experience delayed reactions to injury. This infant requires close monitoring for signs or injury or shock. The RN should care for the infant with type 1 diabetes, who could become ill very quickly.

A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply. the student nurse the nursing instructor the assigned nurse the physician the dietician

the student nurse the nursing instructor the assigned nurse Explanation: The student nurse, nursing instructor, and staff nurse are held to the same standard of care. The tube placement should be confirmed by radiology. The physician and dietician were not involved with the tube placement and following the standard of care with a radiology placement confirmation.

A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? the nurse the surgeon the anesthesiologist the social worker

the surgeon Explanation: It is the role of the surgeon or the person performing the procedure to obtain the informed consent. This consists of informing the client about the procedure, the risks of treatment, the side effects, other types of treatments available, and the effects without the procedure. Nurses, anesthesiologists, and social workers do not obtain informed consent.

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. to ensure efficient and accurate communication to prevent medication errors to ensure client safety to make it easier for clients to understand the medication prescription to make data entry into a computerized health record easier

to ensure efficient and accurate communication to prevent medication errors to ensure client safety Explanation: Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication prescriptions or to make data entry easier.

The nurse is admitting a client to the hospital and fails to implement a turning and positioning schedule for the client identified as a high risk for impaired skin integrity. What are the legal actions that the nurse can be accountable for? Select all that apply. battery intentional tort unintentional tort defamation of character negligence

unintentional tort negligence Explanation: Negligence is an unintentional tort and applies because the nurse failed to implement proper skin care such as a turning schedule. Battery is an assault and did not occur with the failure to implement the turning schedule. Defamation of character is an intentional tort making derogatory remarks about the client which did not occur with this scenario.

A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. assessment of a client who has just returned from the postanesthesia care unit vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip assistance with range of motion exercises for a client diagnosed with Alzheimer's disease education about how to administer a heparin injection to a client diagnosed with deep vein thrombosis administering a sitz-bath to a client who has had perineal surgery 2 days ago

vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip assistance with range of motion exercises for a client diagnosed with Alzheimer's disease administering a sitz-bath to a client who has had perineal surgery 2 days ago Explanation: The nurse, when delegating tasks, needs to keep in mind the scope of practice for the licensed practical nurse (LPN). Vital sign monitoring, assistance with range of motion exercises, and administering a sitz-bath are within the scope of practice for an LPN. The LPN can collect or gather data and reinforce teaching, but the assessment and education are outside the LPN's scope of practice.

In which situation can a client's confidentiality be breached legally? to answer a request from a client's spouse about the client's medication in a student nurse's clinical paper about a client when a client near discharge is threatening to harm an ex-partner when a client's employer requests the client's diagnosis to initiate medical claims

when a client near discharge is threatening to harm an ex-partner Explanation: Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Student papers should not contain identifying information. Release of information is made directly to the client's insurance company, not to the employer.