Professional Nursing Concepts I - Final Review

When a client and family receive the initial diagnosis of colon cancer, the nurse can act as an advocate by: A. Listening carefully to their perceptions of what their needs are. B. Helping the client and family maintain a sense of optimism. C. Determine the client's and family understanding of written materials. D. Teaching family about test diagnosis.

A Rationale: The best nursing advocacy intervention is listening carefully to the client's and family's perceptions of their needs. Studies have demonstrated that these needs are not necessarily what the nurse thinks they are. Intervening without listening carefully may result in a lack of responsiveness to the real needs. Helping the client and family maintain a sense of optimism and hopefulness is appropriate but is not necessarily advocacy. Determining the client's and family's understanding of the results of the diagnostic testing and providing written materials about the cancer site and its treatment are examples of the nurse's role as educator.

A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy? A. Maintaining the clients fluid and electrolyte imbalance B. Providing emotional support to the client and family C. Providing adequate management of pain. D. Maintaining a caloric intake to meet metabolic needs.

A Rationale: After maintaining respirations, the most important and immediate goal of therapy for a client with a serious thermal burns is to maintain fluid, electrolyte, and acid base balance to avoid potential life threatening complications such as shock.

You are suspicious that one of the RNs on shift is intoxicated. What is the best initial action to take? A. Confront her and relieve her of her nursing duties. B. Call the supervisor and report the RN. C. Give her a lecture on substance abuse and hope she doesn't. come to work intoxicated again. D. Ignore the situation.

A Rationale: Calling the supervisor is a secondary measure. Client safety should be addressed first. When another nurse is unable to perform her nursing duties due to substance abuse, she should not be allowed to continue because it puts the client at risk

According to the ANA Code of Ethics, which of the following is INCORRECT: a) Nurses are responsible for only individuals in their care b) Nurses are legally responsible to report other professional of illegal activities c) Nurses should report other nurses suspected of impairment d) Nurses are legally responsible to report immoral or unethical activities

A Rationale: Nurses are advocates for all clients, not just the individuals in their care. Nurses have legal responsibility to report any professional whom they suspect are engaging in illegal, immoral, or unethical activities... A nurse who suspects another nurse of impairment should follow guidelines set forth by the BON... A nurse who suspects and fails to act is in direct violation of the ANA Code of Ethics for nurses.

A client receiving chemotherapy for cervical cancer indicates that she has an advanced directive. She tells the nurse that she worries her children will not honor her wishes if her condition should worsen. In order to facilitate the honoring of the clients wishes, what should the nurse encourage the client to do? a) Discuss her end of life wishes b) Refuse to honor her wishes c) The client should not discuss her end of life wishes but instead find other options

A Rationale: Nurses intervene to educate about legal rights and end of life care. The nurse can assist the patient and family to make informed decisions and act in the patients best interest.

A nurse is providing care to a client with cancer. The client tells the nurse that the care provider is not giving enough information about the client's condition. Which behavior by the nurse demonstrates advocacy? A. Helping the client create a list of questions to ask the care provider. B. The nurse answers the questions herself for the client. C. The doctor has the right to disclose as little or as much information as he or she wants. D. Advise the client to get a second opinion.

A Rationale: Advocacy refers taking the client's side and supports the clients right to information necessary to make his or her own decisions.

A new nurse from the Millennial Generation is hired on the med surge floor and is being oriented by a Veteran nurse. What conflicts are foreseen to arise? (Select all that apply.) a. The veteran nurse feels the younger nurse is arrogant. b. The younger nurse is disillusioned by the veteran nurses' perceived unwillingness to become technologically competent. c. The veteran nurse is dismayed with a perceived lack of professionalism by the millennial nurse related to their dress, hair style, piercings, and tattoos. d. The veteran nurse is open to the idea that the millennial nurse will be taking over a senior position once they are oriented to the floor.

A, B, C Rationale: Pg. 2493. Different generational styles can lead to workplace conflict. Older nurses may experience considerable conflict over younger nurses' behaviors and may describe younger nurses as arrogant, lacking in commitment, and having a "slacker" attitude.

Nurses are strong advocates for vulnerable populations which include (select all that apply) A. Mrs. S who is handicapped to a wheelchair. B. A 10 year old boy with Schizophrenia. C. A 42 year old man with controlled diabetes. D. A 36 year old healthy pregnant women. E. Mr. T who lives on Social Security.

A, B, E Rationale: Nurses have been strong advocates for vulnerable populations such as the poor, those who have a disability or mental illness, and any clients who are unable to advocate for themselves.

By collaborating with case management on a terminally ill patient the nurse is exhibiting which nursing value is being shown? a. Human dignity b. Autonomy c. Integrity d. Enthusiasm

A. Human dignity Rationale: refers to the inherent worth and uniqueness of individuals and populations. The nurse who values and respects all clients and colleagues shows respect for human dignity

An adult client has continued slow bleeding from the graft after repair of an abdominal aortic aneurysm. Because of the client's unstable condition, he is in the intensive care unit where visitors are limited to the family. The client insists on having a visit from a medicine man whom the family visits regularly. How should the nurse interpret this request? A. Medicine men are not approved by the hospital as legitimate health care providers. B. Provision of holistic care requires that the client's belief system is honored C. The principle of justice prohibits giving one client a privilege that other clients are not permitted. D. Faith healers do not meet the standards for clergy exemption from visitation rules

B Rationale: The client's spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client's spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client's spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client's spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff.

Which of the following are roles included in an LPN's scope of practice? SELECT ALL THAT APPLY A. Assess a pressure ulcer and document B. Change the patient's bed linens C. Ambulate a patient 3 days post-op D. Administer IV medication

B, C Rationale: License practical nurses provide direct client care under the direction of an RN, physician, or other licensed practitioner. Page 2458.

Effective nurse leaders (select all that apply): A. Delegate tasks they don't want to do to UAPs B. Are risk takers C. Mentor and direct client care D. Give and receive feedback

B, C, D Rationale: Not A because nurses should not dump work they don't want to do onto others. They will delegate tasks to save time and benefit the client.

A nurse is discussing the different type of task thadt can be given to a UAP, which of the following are appropriate tasks. Select all that apply A. Interpreting data B. Taking vitals C. Assessment D. Measuring I&O

B, D Rationale: UAP should not be delegated any form of assessment or interpretation as it is out of their scope of practice.

Which of the following is not one of the four dimensions of advocacy? A. Being a client advocate B. Educating providers and others C. Following through or following up D. Going above and beyond

B. Rationale : The four dimensions of advocacy are being a client advocate, following through or following up, providing resources, and going above and beyond.

Situation: You are not new in your department and you had been there for almost three years. Miss A, your previous nurse manager was considered strict and authoritative in implementing the protocols in your area. She would make your schedule fixed unless you will inform her two weeks before for any change of shift. On the contrary, your new nurse manager, Miss B, schedules a monthly staff meeting for any significant matters in your department. She is not so lax but makes it up to collect suggestions from all of you before making decisions.1. If you are to choose which one of your nurse managers described above reflects a democratic type of leadership, who is she? A. Miss A B. Miss B C. Both of them D. None of the above

B. Rationale: A democratic leadership style offers and gives suggestions, but lets the whole group do the planning. Miss B basically exhibits a democratic leadership since she would allow the group decide and plan for any significant matter in the department.

Which of the following is the best action to take when it comes to being assigned a task that you feel is out of your scope of practice? a. Attempt to do the task, even if you are unsure of your abilities b. Politely decline the task and provide rationale to supervisor c. Document that task was performed even though it was not to avoid punishment d. Ask another health care provider to do the task for you

B. Rationale: Each nurse or other licensed or unlicensed healthcare provider is responsible for his or her own actions. Anyone who feels unqualified to perform a delegated task must decline to perform it

Which of the following is the type of leader who makes decisions for the group based on the belief that individuals are externally motivated and are incapable of independent decision-making? a. Democratic leader b. Autocratic leader c. Formal leader d. Bureaucratic leader

B. Rationale: Linked to a dictator, the autocratic leader determines policies and gives orders and directions to the group. Under this leadership style, the group may feel secure because procedures are well defined and activities are predictable

The nurse administered Lispro (Humalog) insulin 10 units subcutaneously at 0700 to a patient. Which is the best time for the nurse to assess the patient for signs of hypoglycemia? A. 0705 B. 0830 C. 1030 D. 1130

B. 0830 Rationale: For rapid acting insulin administered subcutaneously, the onset begins within 15 minutes, the peak is 1-2 hours, and the duration is 3-4 hours. Since the peak effect of this medication is when it will be working the best to lower the blood glucose levels, the nurse should check the patient 1 to 2 hours afterwards to check for signs of hypoglycemia (Davis Drug Guide, 2013, p. 691)

An 83 year old male recently diagnosed with type II diabetes is attending a follow up appointment after a recent hospitalization for hyperglycemia at his primary care physician's office. While there, the doctor discusses with the patient the events that led up to, and they determine it was because of his lack of knowledge and discipline. The nurse suggests to the doctor that an insulin pump may be a good option for this patient because it will monitor his blood glucose levels automatically. What is this an example of? A. Human Dignity B. Advocacy C. Social Justice D. Integrity

B. Advocacy Rationale: the nurse has the responsibility to ensure the client has access to health care services that meet health needs.

A nurse is taking care of a 91 year old female with atrial fibrillation and is told she needs an artificial pacemaker to continue with quality of life. The patient tells the nurse she would like to discuss this with her sons because they are making the ultimate decision and she "does not want to make her kids suffer if anything were to happen to her during the procedure." The patient is told a decision needs to be made by the end of day or she will be discharged. What ethical value is being questioned? A. Altruism B. Autonomy C. Human Dignity D. Social Justice

B. Autonomy Rationale: the right to self-determination. Professional practice reflects autonomy when the nurse respects the clients rights to make decisions about their healthcare. Autonomy was being questioned because she was given an ultimatum on the final decision regarding her care.

What is the definition of Altruism as stated in volume 2 of your nursing text book? a. Acting in accordance with an appropriate code of ethics and accepted standards of practice. b. Inherent worth and uniqueness of individuals and populations. c. Concern for welfare and wellbeing of others. d. The right to self-determination.

C Rationale: "Altruism is a concern for the welfare and wellbeing of others. In practice, altruism is reflected in the nurse's concern for the welfare of clients, other nurses, and other healthcare providers"

The charge nurse is conducting a staff meeting and is asking for feedback from nursing staff about the new patient care policies. What type of leadership style is this? A. Autocratic B. Laissez-faire C. Democratic D. Situational

C Rationale: Democratic leadership encourages group decision making

A nursing working on med/surg is very behind schedule and asks the UAP to go suction room 415's tracheal tube and then disappears into the med room without giving the UAP time to respond. The UAP had only worked at the hospital for a week and is unfamiliar with this skill. The nurse is? A. Over delegating B. Reverse delegating C. Under delegating D. Improperly delegating

C Rationale: Under delegation occurs when the delegator 1. Fails to transfer full authority to the delegate 2. Takes back responsibility for aspects of the task 3. Fails to equip or direct the delegate

Which one of the tasks may not be delegated to a UAP? A. Collection of vital signs B. Measuring I&O C. Assessment D. Emptying foley catheters

C Rationale: What can be delegated? • Noninvasive and nonsterile treatments such as emptying Foley catheters and providing hot/cold soaks • Collection of and reporting data such as vital signs, height and weight, and capillary blood sugar results • Hygienic care activities such as bathing and toileting, assistance with feeding, and assisting with ambulation • Socialization activities What cannot be delegated? • Patient assessments (data collection is not assessment; assessments require interpretation) • Planning and evaluation of nursing care • Development of plan of care • Health teaching and health counseling (unless it is reinforcement of previously taught material)

The nurse is caring for a patient with rheumatoid arthritis who states, "The joints in my hands and feet have been really sore for the last 2 years." Which is the best nursing diagnosis? A. Impaired comfort B. Acute pain C. Chronic pain D. Impaired physical mobility

C. Chronic Pain* Rationale: Impaired comfort: Perceived lack of ease, relief, and transcendence in physical, psycho-spiritual, environmental, cultural, and/or social dimensions. Acute pain: An unpleasant sensory and emotional experience... with an anticipated or predictable end. Chronic pain: An unpleasant sensory and emotional experience...without an anticipated or predictable end and a duration of greater than 3 months. Impaired physical mobility: Limitation in independent, purposeful physical movement of the body or one of the extremities.

The nurse is caring for a patient who had an emergency cesarean birth yesterday; the newborn was transported to another facility. The patient wants to breast feed and pumps small amounts of breast milk. Which is the best nursing diagnosis? A. Insufficient breast milk B. Ineffective breastfeeding C. Interrupted breastfeeding D. Alteration in nutrition, less than body requirements

C. Interrupted breastfeeding* Rationale: Insufficient breast milk: low production of maternal breast milk. Ineffective breastfeeding: Difficulty providing milk to an infant or small child directly from the breasts, which may compromise nutritional status. Interrupted breastfeeding: Break in the continuity of providing milk, directly from the breasts, which may compromise the nutritional status. Readiness for enhanced breastfeeding: A pattern of providing milk, directly from the breasts, which may be strengthened.

Who is responsible for obtaining informed consent from a patient who is preparing for abdominal surgery? a. The LPN b. The RN c. The Physician d. The Nursing Assistant

C. The physician Rational: It is the responsibility if the physician. Although the nurse assumes the responsibility for witnessing the signature, they are not legally accountable for obtaining Source : Pearson, Vol. 2, pg. 2580

According to the Joint Commission, which is not included in patient rights? a) You have the right to be informed about the care you receive b) You have the right to refuse care c) You have the right to know when something goes wrong with your care d) You have the right to not answer questions asked by your health care team

D Rationale: Answering questions from your health care team about your health status is a patient responsibility.

A nursing student is employed and working as an unlicensed assistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be graduating soon. A nurse asks the UAP if he has performed a urinary catheritization on clients while in school. When the UAP says yes, the nurse asks him to help her by doing a urinary catheterization on a post-surgical client. What is the best response by the UAP? a. "Let me get permission from the client first." b. "Sure which client is it?" c. "I cannot do it unless you supervise me." d. "I cannot do it. Is there something else I can help you with?"

D. Rationale: A sterile invasive procedure that places the client at significant risk for infection is outside the scope of practice of a UAP. Even though the UAP is a nursing student, the agency job description should be followed.

A teenage patient comes in to the emergency room with sharp pain in her lower right quadrant, nausea and vomiting, abdominal bloating and a low grade fever. Before any interventions have been performed, the patient expresses that she's suddenly free of pain. The nurse immediately recognizes that the relief of pain is a sign that the appendix has burst. According to Benner and colleagues (1982), this nurse displays which level of proficiency? A. Novice B. Competent C. Proficient D. Expert

D. Rationale: Nurses with expert level proficiency have an intuitive grasp of the situation and readily zeros in on the problem and solution without spending much time problem solving.

A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? A. the RN need not to carry out further assessment because the LPN is very experienced and trustworthy B. the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively C. the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic D. the RN assesses the client, checks the client's surgical notes, and gathers additional data before calling the surgeon

D. Rationale: The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon

A client in a long-term care facility has been complaining of care that is being given by one of the nurses. A new nurse is assigned to the client and is asked by the family what options they have in making a formal complaint. The nurse's best action is to: A. Refer them to the nurse manager. B. Refer them to the physician. C. Have them contact the risk manager. D. Offer to notify the agency's client advocate.

D. Offer to notify the agency's client advocate. Rationale: Most agencies have client advocates, whose job is to assist the client when conflict arises and to protect the client's rights. Neither the nurse manager nor the physician is the appropriate person to deal with the client. A risk manager is concerned with client and staff injuries.

What concepts relate to advocacy? a. Legal issues b. Professional behaviors c. Culture and diversity d. Healthcare systems e. All the above

E. All the above Rationale: "Nurses must take many other concepts into consideration when advocating for their clients. Examples include ethics, legal issues, professional behaviors, culture and diversity, and healthcare systems"

Which two professional bodies guide the ethical practices in nursing healthcare? Select all that apply. A. The American Nurses Association B. The international council of nurses C. The joint commission D. The American hospital association

A & B Rationale: The ANA code of ethics and ICN outlines the ethical standards that nurses are expected to use inform the behavior toward clients and their families , other nurses and health care professionals, and the larger community.

Identify examples of abuse and inappropriate behaviors in in the workplace: SELECT ALL THAT APPLY a. Supplying clients with drugs or alcohol in return for favors b. Inhumane physical facilities c. Sexual misconduct d. Ordering lunch for other employees

A, B, C Rationale: Although providing care to clients in mental health settings can be challenging, nurses and other staff members should never engage in abusive or unprofessional behavior

A nurse is an effective advocate when he/she does the following. Select all that apply. A. Is assertive B. Aware that conflicts may arise that require consultation, confrontation or negotiation C. Work with community agencies and lay practitioners D. Recognizes that the rights and values of clients and families must take precedence when they conflict with those of health care providers

A, B, C, D

Which of the following are acceptable tasks to delegate to UAP? Select all that apply. A. Draining foleys B. Obtaining vital signs C. Administering medications D. Feeding

A, B, D Rationale: According to Box 39-2 of our text, nurses are responsible for administration of medications. Regular, routine tasks that the patient is used to are able to be delegated.

A nurse manager is working to develop an optimal schedule and build effective work teams. In a multigenerational staff, the nurse is establishing a blend of each generation and recognizes the strengths of each specific cohort, which fits the following strength: when technology fails, Nurse A can provide education and assistance for a transition back to previous routes of assessment and patient care. A. Baby Boomer Nurses B. Veteran Nurses C. Millennial Generation Nurses D. Generation X Nurses

B Rationale: Veteran nurses have wisdom and organization history. They like working in teams with designated leaders and prefer personal forms of communication. During episodes when technology fails, they can bring back previous methods of nursing care.

A nurse is conducting a physical assessment on an adolescent who doesn't want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse can implement in this situation? a) Because the adolescent is a minor, inform her parents about her medical history b) Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor. c) Respect adolescents wishes and maintain confidentiality d) Discuss the adolescent's medical history with her parents and thoroughly document it in the medical record.

C Rationale:In keeping with the principe of autonomy, nurses are obligated to respect clients wishes and abide by patients confidentiality of health information.

Which of the following theories states that learning takes place when an individual's reaction to a stimulus is either positively or negatively reinforced? a. Social learning theory b. Temperament theory c. Behaviorist theory d. Resiliency theory

C Rationale: "Behaviorist theory states that learning takes place when an individual's reaction to a stimulus is either positively or negatively reinforced. The more rapid, consistent, and positive the reinforcement, the more likely a behavior is to be learned and retained."

A nurse demonstrates proper client teaching when they do all of the following except. A. Asses the clients learning needs on admission B. Plan appropriate teaching methods for client and appropriate interventions C. Insure that access to client information is made available only to appropriate staff members D. Asses your own assumptions and values about receiving care information and the best way to receive that information

C. Rational: Insuring access to client information demonstrates the concept of confidentiality not teaching

As part of a good work ethic, actions a nurse can take to protect their own health and safety include all of the following except: 1. Getting adequate amounts of sleep at night 2. Getting a flu shot each year 3. Avoiding unnecessary risks 4. Eating fast food for at least one meal every day

4 Rationale: All of these activities protects a nurse's health and safety while eating fast food every day would be detrimental to your health because it does not provide adequate nutrition. These measures help to ensure that the nurse can continue to do their job adequately.

Which of the following is task that can be delegated to a UAP: 1. Assessing a patient upon arriving to the emergency room 2. Providing client education 3. Interpreting lab values 4. Suctioning chronic tracheostomies

4. Rationale: All of the other choices cannot be given to a UAP because it is out of their scope of practice. Within their scope of practice is suctioning a tracheostomy if it is chronic.

An elderly patient reports nausea and seeing bright halos around lights recently. The nurse reviews the patient's daily medications: Aspirin, Digoxin, Morphine, and Thyroxin. Which vital sign should the nurse assess prior to administering medications? A. Temperature B. Blood pressure C. Heart rate D. Respiratory rate

C. Heart rate Rationale: An age related decreased renal clearance may lead to toxic levels of Digoxin (Lanoxin). The first signs are abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, or arrhythmias. The nurse should assess an apical heart rate to help determine if the patient's subjective signs are related to the medication (Davis Drug Guide, 2013, p. 424)

Which of the following is NOT one of the five rights of delegation? A. Right task B. Right circumstances C. Right day D. Right direction

C. Right day Rationale: the five rights of delegation are; right task, circumstances, person, direction, and supervision. Day is of no importance.

A registered nurse arrives at work and is told to "float" to the ICU for the day because the ICU is understaffed and needs an additional nurse to care for the clients. The nurse has never worked in the ICU. Which of the following is the most appropriate nursing action? A. refuse to float in the ICU B. call the hospital lawyer C. call the nursing supervisor D. report to the ICU and identify tasks that can be safely performed

D. Rationale - floating is acceptable and legal practice. The nurse floated to a unit until will be given orientation; be assigned to care for stable patients or those with conditions similar to her training experience.

A hospital patients responsibilities include all of the following except A. Tell your healthcare team how you feel. B. Provide information about your health, past illnesses, and use of medications. C. Recognize the effects of your lifestyle on your health, and work with your hospital team to change your lifestyle as necessary. D. Do what your doctor says without asking any questions.

D. Rationale: Patients rights include listening to instructions, reading written material given to you, and ask questions if you do not understand something.

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with the family. The nurse is acting as the patients a. Educator b. Caregiver c. Case manager d. Advocate

D. advocate Rationale: The overall goal of the client advocate is to protect client's rights. The nurse provides clients with the information they need to make informed decisions and supports all client's rights to make their own healthcare decision.

True or false. The five levels of nursing progression include all of the following: Novice, advanced beginner, competent, proficient, expert.

True Rationale: In the acquisition and development of a skill a nurse can pass through five levels of proficiency (novice, adv. beginner, competent, proficient, expert).

A student nurse overhears an RN telling a patient at a MHCH that the RN does not need to explain their medications to them because they wouldn't understand anyway. The student nurse knows this is a form of abuse. True or false.

True. Rationale: Abuse in a mental health care hospital includes verbal harassment, threats, sarcasm, and putdowns.

The patient care tech (PCT) is asked to remove a foley, but feels unqualified to do that skill. What action should follow? a. Remove the foley on their own. b. Have a another PCT assist. c. Tell the charge nurse. d. Decline the task.

D. Rationale: Safety alert pg. 2468. Each nurse or other unlicensed or licensed health care provider is responsible for his or her own actions. Anyone who feel unqualified to perform a delegated task must decline to perform it.

A floor nurse has attempted to start and IV two times and after two unsuccessful attempts, she asked the charge nurse for assistance. The charge nurse responds in front of everyone at the nurse's station, " I can't believe you aren't able perform such a basic skill." The charge nurse is exhibiting? A. Abuse of power B. A negative attitude C. Low integrity D. incompetence

A Rationale: Abuse of power is any attempt to use one's position or authority to shame, control, demean, humiliate, or denigrate another individual in order to gain emotional, psychological, or physical advantage over that individual.

Which guidelines define and regulate what the nurse may and may not do as a professional? A. Nurse Practice Act B. State Legislature C. Facility policies and procedures D. Standards of Care

A Rationale: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state.

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/ Select all that apply. a. Auscultate breath sounds b. Complete in depth admission assessment c. Initiate the nursing care plan d. Evaluate the patients technique for using MDI's e. Administer medications via metered dose inhaler (MDI)

A, E Rationale: The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient's abilities require additional education and skills. These actions are within the scope of practice of the professional RN.

During a floor meeting, the charge nurse, Lisa, verbalized strict policies and responsibilities. However, when other nurses try to give creative option they were not acknowledged. What leadership theory is nurse Lisa exhibiting? A. Autocratic leader B. Democratic leader C. Laissez-faire leader D. Bureaucratic leader

A. Rationale: An autocratic leader makes decisions for the group based on the belief that individuals are externally motivated and are incapable of independent decision making. Page 2489

You are the day nurse who just completed your morning rounds and a patient tells you that the night nurse did not attend his repeated calls. Which of the following interventions is the most appropriate to be taken by the nurse as an advocate? A. Discuss the patient's complains with the night nurse and clarify the incident B. Report the incident directly and submit the documentation to the charge nurse C. Promise to provide all the care for the patient D. Observe the other nurse to determine if this negligence is repeated

A. Rationale: The nurse represent the patient and calls for his/her rights. The first things is to clarify the complaint with the nurse involved. If the issue is not resolved, it should then be reported to the manager. Source: Pearson, Vol.2, pg. 2556.

The nurse is caring for a patient with diabetes mellitus and hypercholesteremia,who was admitted for possible chronic renal disease. The patient is taking Glargine (Lantus) insulin and Simvastatin (Zocor).In case of hypoglycemia, which is the best liquid for the nurse to teach the patient to drink? A. apple juice B. whole milk C. grapefruit juice D. orange juice

A. Apple Juice Rationale: Although all of these liquids would be acceptable in an emergency, the patient's history will help to determine the best option. In chronic renal disease, the kidneys have difficulty excreting electrolytes (OJ is high in potassium). For elevated cholesterol, skim milk would be preferable. Also, grapefruit juice can increase the risk of Simvastatin toxicity (Davis Drug Guide, 2013, p. 645)

The nurse caring for a client who does not speak English requested interpreter services to assist with care. Which client right did the nurse maintain? A. Information disclosure B. Complaints and appeals C. Respect and nondiscrimination D. Participation in treatment decisions

A. Information disclosure The patient bill of rights on information disclosure states that if a client speaks another language, help should be provided so that the client can make informed healthcare decisions (see Box 44-7). Complaints and appeals refer to a fair, fast, and objective review of a client's complaint against healthcare personnel or an agency. Respect and nondiscrimination refer to considerate and respectful treatment of the client by healthcare personnel. Participation in treatment decisions refer to the client's right to know treatment options and be part of care decisions.

When the nurse gives the client freedom to choose their own treatment options, which of the ethical nursing values is the nurse displaying? A. Altruism B. Autonomy C. Human Dignity D. Integrity

B Rationale: Autonomy is the right to self determination. Professional practice reflects autonomy when the nurse respects client's right to make decisions about their health care.

Which of the following is NOT a professional behaviors nurses use to meet their responsibility of nursing? a. Collaboration b. Dumping c. Communication d. Ethics e. Delegating

B. Dumping Rationale: Collaborating helps to contributes to sharing opinions of other nurses as professional and improves quality of care delivered to client. Adherence to the strict moral and ethical code, ANA Code of Ethics for Nurses helps to improve delivery of client care and maintain accountability.

The nurse's assessment of an adult patient reveals: T 98.2 F, HR 88, RR 28 and shallow, BP 118/76, O2 sat 98%, productive cough, and clear lung sounds. Which is the best nursing diagnosis? A. Ineffective airway clearance B. Ineffective breathing pattern C. Impaired gas exchange D. Decreased cardiac output

B. Ineffective breathing pattern* Rationale: Ineffective airway clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Ineffective breathing pattern: Inspiration and/or expiration that does not provide adequate ventilation. Impaired gas exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. Decreased cardiac output: Inadequate blood pumped by the heart to meet the metabolic demands of the body.

A 17 year old male is admitted for Acute Respiratory Distress Syndrome and communicates to the nurse that they wish they had never given in to smoking with his high school friends. What stage of moral development was the patient in when he gave in to peer-pressure and started smoking cigarettes? a) Social Contract Legalistic Orientation b) Interpersonal Concordance Orientation c) Punishment and Obedient Orientation d) Universal Ethical Principle Orientation

B. Interpersonal concordance orientation Rationale: Young adults and adults fall into the stage of moral development. In Interpersonal Concordance Orientation, individual's behavior is driven by the individuals peer's approval or societal reward.

A female patient feels as though she is not going to live much longer after being diagnosed with lung cancer. The physician informed her that with treatment and therapy she could go into remission. She tells the nurse she wants to write her living will and the nurse agrees. Which ethical value does this nurse posses? A. Human dignity B. Social Justice C. Autonomy D. Integrity

C. Autonomy Rationale: Although the nurse understands that the patient can go into remission, the nurse is letting the patient control the few things she has control of. The nurse is right to allow the patient to that type decision because it is what that patient wants. The nurse can still remind the patient that she can go into remission but it is still in the nurse's best interest to all the patient to make decisions.

Which of the following is NOT one of the rights of delegation? A. Right circumstances B. Right person C. Right direction D. Right place

D Rationale: right place is not a Right of delegation

Which of the following cultures does not view discussions of advance directives issues like DNR orders and CPR as physically and emotionally harmful to the patient? A. Filipino B. Native American C. Chinese D. Argentinians

D. Argentinians Rationale: Chinese, Native American, and Filipino cultures find advanced directives conversations physically and emotionally harmful to the patient. It violates the ethical principal of nonmaleficence.