Sleep, wound care, ethics and legal EAQ

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? A. Primary B. Secondary C. Superinfection D. Nosocomial

D. Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting? A. The nurse should focus on doing no harm. B. The nurse should keep promises made to clients. C. The nurse should respect the autonomy of clients. D. The nurse should keep the best interests of the client in mind.

A. The nurse should focus on doing no harm. To comply with the ethic of nonmaleficence, the nurse should focus on doing no harm. The healthcare ethic fidelity requires the nurse to keep promises made to the client by following through on the plan of care. To comply with the ethic of autonomy, the nurse should include the client in the decision-making process when developing a care plan. To comply with the healthcare ethic of beneficence, the nurse is required to keep the best interests of the client in mind when providing care.

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? A. Encircle the drainage on the dressing. B. Irrigate the suction tube with sterile saline. C. Clean the drainage port with an alcohol wipe. D. Compress the container before closing the port.

D. Compress the container before closing the port

A nurse is caring for a client who had head and neck surgery. Postoperatively, the nurse positions the client's head in functional alignment to prevent what complication? A. Cervical trauma B. Laryngeal spasm C. Laryngeal edema D. Wound dehiscence

D. Wound dehiscence Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.

A nursing instructor asks a nursing student about the sleep pattern of teenagers. Which statements made by the student indicate adequate learning? Select all that apply. A. Teenagers often have reduced hours of sleep. B. Teenagers often suffer from restless leg syndrome. C. Teenagers get roughly 7.5 hours of sleep each night. D. Twenty percent of a teen's sleep cycle is rapid eye movement (REM) sleep. E, Teenagers resist sleeping because they are unaware of fatigue.

A, C The typical adolescent is subject to a number of changes, such as school demands, after-school social activities, and part-time jobs, that reduce the time spent sleeping. On average, teenagers get about 7.5 hours of sleep per night; preschoolers sleep an average 12 hours a night. Restless leg syndrome is common in young adults, not teenagers. Young adults, not adolescents, have 20% of their sleep time in REM sleep. Preschoolers often resist sleeping because they are unaware of fatigue or have a need to be independent.

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? A. Whether the client is allowed to give consent B. That the client cannot make informed decisions about healthcare C. Whether the client is permitted to give voluntary consent when parents are not available D. That the client probably will be unable to choose between alternatives when asked to consent

A. Whether the client is allowed to give consent A person is legally unable to sign a consent until the age of 18 or 19 years (depending upon individual state or provincial laws) unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.

Before a treatment requiring informed consent can be performed, what information must the client be given? Select all that apply. A. The cost of the treatment B. Alternative treatment options C. The risks and benefits of the treatment D. The risks involved in refusing the treatment E. The nature of the problem requiring the treatment

B, C, D, E

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? A. Institute the prescribed blood transfusion because the client's survival depends on volume replacement. B. Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C. Phone the primary healthcare provider for an administrative prescription to give the transfusion under these circumstances. D. Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought.

D. Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a healthcare proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the primary healthcare provider for an administrative prescription are without legal basis, and the nurse may be held liable.

A nurse is educating a client regarding a do-not-resuscitate (DNR) order. What information should the nurse provide? Select all that apply. A. "Do-not-resuscitate orders should be reviewed routinely by the primary healthcare provider." B. "A primary healthcare provider should make every effort to revive a client if a do-not-resuscitate order exists." C. "Legally competent adults may issue a do-not-resuscitate order verbally or in writing after receiving proper information about it." D. "Primary healthcare providers should check for a DNR order before deciding to perform cardiopulmonary resuscitation." E. "A DNR order may be attached to the client's medical orders without any legal proof of consultation regarding the order."

A, C, D Primary healthcare providers are required to review do-not-resuscitate orders routinely to determine whether there is a need for any change. A do-not-resuscitate order may be issued by a legally competent adult, either verbally or in writing, after the primary healthcare provider has provided proper information about it. It is essential to check for a DNR order, because CPR should not be performed if such an order exists. If a client has issued a do-not-resuscitate order, the primary healthcare provider should not make an effort to revive the client. The do-not-resuscitate order should be attached to the client's medical records along with proper documentation showing that the client has consulted with the primary healthcare provider or family members.

A nurse is changing the dressing of a postoperative client. The nursing assistant informs the nurse that another client has fallen down near the nursing station after losing consciousness. What is the best nursing action in this situation? A. Attend to the client who lost consciousness. B. Delegate the dressing change to the nursing assistant. C. Delegate the care of the unconscious client to the nursing assistant. D. Complete the dressing as the open wound may increase infection risk.

A. Attend to the client who lost consciousness. Loss of consciousness may pose a threat to the client's safety and survival, and is a high-priority need. Therefore, the nurse should attend to the unconscious client. The nursing assistant may not have the required knowledge and skills to perform a dressing change. The care of an unconscious client may need critical nursing assessments and clinical decision-making, and should not be delegated to the nursing assistant. Risk of infection is not a threat to survival, and is considered an intermediate need.

A nurse should employ which technique to maintain surgical asepsis? A. Change the sterile field after sterile water is spilled on it. B. Put on sterile gloves and then open a container of sterile saline. C. Place a sterile dressing no more than half an inch from the edge of the sterile field. D. Clean the surgical area with a circular motion, moving from the outer edge toward the center.

A. Change the sterile field after sterile water is spilled on it. A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique? A. Exercise daily B. Read in bed before sleeping C. Avoid naps during the daytime D. Have a hot cup of tea at bedtime

A. Exercise daily Exercise, such as walking or other activity appropriate for the older adult, will be invigorating during the day and prime the client for a better night's sleep. Reading is relaxing before sleeping, but the client should avoid reading in bed; a pattern of using the bed to sleep should be established. Naps should be limited, but not necessarily eliminated; research has demonstrated that a short nap (20 to 30 minutes) in the afternoon will not appreciably affect nighttime sleep. Caffeinated beverages should be avoided before bedtime because caffeine is a stimulant that generally interferes with sleep.

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound? A. In the preoperative period B. 2 days before discharge C. On the first postoperative day D. During the first dressing change

A. In the preoperative period Teaching for the postoperative period should begin as soon as the decision for surgery is made; knowledge of what to expect decreases anxiety and may improve adherence to the treatment regimen. Several days before discharge is too late; the client must have time to ask questions and demonstrate the ability to care for the wound. Teaching begins preoperatively. On the first postoperative day the client may be in too much discomfort to concentrate on learning. During the first dressing change the client may be in too much discomfort to concentrate on learning.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? A. Keeps the area free of microorganisms B. Confines microorganisms to the surgical site C. Protects self from microorganisms in the wound D. Reduces the risk for growing opportunistic microorganisms

A. Keeps the area free of microorganisms Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound apply to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

A registered nurse is explaining the importance of capitation to a nursing student. What information should the nurse provide? Select all that apply. A. Capitation is used to review the quality, quantity, and cost of hospital care. B. Capitation influences the way healthcare providers deliver care in all types of settings. C. Capitation means that primary healthcare providers are paid a fixed amount per client of a health care plan. D. Capitation identifies and eliminates the overuse of diagnostic and treatment services ordered by primary healthcare providers for Medicare. E. Capitation aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standards of care at the lowest cost.

B, C, E Capitation influences the way healthcare providers deliver care in all types of settings. Capitation means that health care providers are paid fixed amount per client enrolled in a health care plan. Capitation aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standards of care at the lowest cost. The professional standards review organizations (PSROs) are responsible for reviewing the quality, quantity, and cost of hospital care. The utilization review (UR) committee identifies and eliminates overuse of diagnostic and treatment services ordered by primary health care providers caring for clients on Medicare.

A client with rheumatoid arthritis of the knee has undergone knee replacement surgery. What actions by the nurse and other members of the health care team help to provide efficient client care? Select all that apply. A. Provide financial assistance to the client. B. Follow interventions to reduce hospital stay. C. Encourage the client to use herbal therapy. D. Provide cost-effective treatment to the client. E. Help the client in making health care decisions.

B, D Health care professionals should measure and grade the quality of care and treatment that they provide to the client. This helps improve their services and provide best care to the client. If health care professionals follow interventions to reduce hospital stay and provide cost-effective treatment, they deliver efficient care to the clients. Health care professionals need not provide financial assistance to the client; rather, they can try to provide cost-effective care. Health care professionals should not help the client in making decisions because that reduces the client's self-esteem and decision-making ability. Health care professionals should not encourage the client to use herbal therapy because it is not clinically tested and may cause adverse effects in the client.

At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 pm tonight?" What is the nurse's best response? A. "I will give one capsule tonight before bedtime." B. "I will get a prescription so that the medicine can be taken." C. "Does your healthcare provider know about your child's allergy?" D. "Did you ask your healthcare provider if your child should have this tonight?"

B. "I will get a prescription so that the medicine can be taken." Legally, a nurse cannot administer medications without a prescription from a legally licensed individual. The nurse cannot give the medication without a current healthcare provider's prescription; this is a dependent function of the nurse. The nurse should not ask if the healthcare provider is aware of the problem; it is the nurse's responsibility to document the client's health history. It is the nurse's responsibility to review the healthcare provider's prescriptions and question them when appropriate.

A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? A. Ambivalent feelings are present and acknowledged. B. A sedative type of medication has been given recently. C. A complete history and physical has not been performed and recorded. D. A discussion of alternatives with two primary healthcare providers has not occurred.

B. A sedative type of medication has been given recently. Sedation may interfere with the client's knowledge of the consent form. Many clients face contradictory feelings regarding their impending surgery, but their consent is legal unless they withdraw the consent. A complete history and physical examination are needed before surgery, but they do not affect the legality of consent. A second opinion is not required for a consent to be legal.

A client is admitted to the hospital for acute pain in the hip, and a total hip replacement surgery is scheduled. The client was diagnosed recently with early dementia. The client appears oriented and alert and responds appropriately when interviewed. When the nurse is providing preoperative teaching, the client says, "I don't want to have that surgery." The client's spouse voices a desire to proceed with the surgery to provide relief for the client. How should the nurse respond? A. Discuss with the client feelings about having surgery. B. Ask the client if a power of attorney for health care has been established. C. Continue with preparation for surgery as the spouse has requested. D. Continue with teaching, ensuring that the client understands the process.

B. Ask the client if a power of attorney for health care has been established. Consent for surgery should be given by the client; the spouse cannot do this unless he or she has power of attorney for health care. Although it is important to discuss feelings with the client, this does not address the legal issue. The legal issue needs to be clarified first. If the client does not want surgery, preoperative teaching probably will not be effective, because the client will not be receptive. The legal issue needs to be clarified first.

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is what? A. Early ambulation B. Coughing and deep breathing C. Wearing antiembolic elastic stockings D. Maintenance of a nasogastric tube

B. Coughing and deep breathing The client who has a cholecystectomy will have difficulty taking deep breaths and coughing because of the location of the surgical incision. Therefore it is important to instruct the client preoperatively to improve compliance with the procedure in the early postop period. Although ambulation, antiembolism stockings, and maintaining a nasogastric tube, if ordered, are important postoperative procedures, maintaining the airway and preventing further pulmonary problems is the priority.

A 20-year-old developmentally challenged woman is a resident in a group home. She has had four abortions in the past 2 years, and the agency supervisor recommends that she be sterilized. It is obvious that the client is unable to exercise informed consent for sterilization. The nurse understands that the procedure cannot be performed without legal consent from whom? A. Next of kin B. Court-appointed individual or group C. Agency designated to perform the abortion D. Organization or agency licensed to administer the group home

B. Court-appointed individual or group In the United States each state has its own restrictions; the approval of a court-appointed individual or group is required to give legal consent. The other options do not meet the legal requirements for consent. The states have an obligation to oversee the best interests of the mentally disabled, and the court must be involved.

The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full-thickness burns to the chest, right arm, and upper legs as the result of a car fire. What should the nurse do first when caring for this person? A. Wrap the person with a warm blanket. B. Cover the person with a clean, dry sheet. C. Apply sterile dressings to burned areas. D. Remove the person's adhered clothing.

B. Cover the person with a clean, dry sheet. While administering emergency care outside of the hospital setting, covering exposed burned surfaces with a clean, dry sheet will limit contamination by microorganisms and prevents exposure to air, which increases pain. A warm blanket can trap the heat, promote vasodilation, and worsen the inflammation process occurring on the burns. Clean dressings, not sterile, are acceptable in an emergency out in the field. Removing clothing from the areas that are burned is unsafe as it will further traumatize the wounds. NOTE: If this client were in a sterile hospital setting, the nurse would not place a clean, dry sheet onto the wound because it can stick to and injure the wound.

A client on the psychiatric unit is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT). Because of the client's profoundly depressed behavior, the nurse doubts that the client can provide informed consent. What should the nurse's initial intervention be? A. Consulting with the hospital's legal staff and following their recommendation B. Having the client verbalize understanding and the outcomes of the procedure C. Asking the client to sign the consent form, because the client has not been declared incompetent D. Suggesting to the primary healthcare provider that a family member sign the consent form for the client

B. Having the client verbalize understanding and the outcomes of the procedure The client's understanding should be assessed first. Depressed clients are often cognitively stable and capable of providing legal consent. Consultation with the hospital's legal staff may eventually be necessary, but it is not the initial intervention. The client's rights are not protected if the nurse elicits consent for a procedure when the nurse believes that the client does not comprehend the information; just because the client has not legally been determined to be incompetent, it does not mean that the client is competent; further assessment is necessary. Unless the client has legally granted the family member authority to make decisions, or the family member has been appointed as the client's guardian by the court, having a family member sign the consent is illegal.

The registered nurse (RN) delegates the tasks of caring for a client with pressure ulcers. The client suffers further tissue necrosis during treatment. What could be the reason for this condition? A. Cleaning of the wound by the registered nurse (RN) B. Performing irrigation of the wound by the patient care associate (PCA) C. Administering of oral analgesics by the licensed practical nurse (LPN) D. Repositioning the client every 1-2 hours by the licensed practical nurse (LPN)

B. Performing irrigation of the wound by the patient care associate (PCA) The patient care associate (PCA) is not authorized to irrigate the wound as improper technique can lead to tissue damage. The RN is qualified to perform wound care; therefore, cleaning the wound is not likely to lead to tissue necrosis. Pressure ulcers are associated with pain. The LPN administering oral analgesics may relieve the pain, but it will not cause tissue necrosis. Having the licensed practical nurse (LPN) reposition the client every 1 or 2 hours will minimize the risk of tissue necrosis due to pressure ulcers.

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do? A. Put the unopened sterile glove package carefully on the sterile field. B. Remove the sterile drape from its package by lifting it by the corners. C. Don sterile gloves before opening the package containing the field drape. D. Pour irrigation liquid from a height of at least 3 inches (2.5 cm) above the sterile container.

B. Remove the sterile drape from its package by lifting it by the corners. The outer 1 inch of the sterile field is considered contaminated and can be touched without wearing sterile gloves. The outside of an unopened sterile glove package is not sterile. The field will become contaminated if the unopened package is placed on the sterile field. The outer package, which contains a sterile field drape, is not sterile; if it is touched with sterile gloves, the sterile gloves will become contaminated. Liquids should be poured from a height of 4 to 6 inches (10 to 15 cm); this ensures that the solution bottle does not contaminate the sterile container.

A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? Select all that apply. A. Eating a heavy snack near bedtime B. Reading in bed before shutting out the light C. Leaving the bedroom when unable to sleep D. Drinking a cup of warm coffee with milk at bedtime E. Exercising in the afternoon rather than in the evening F. Drinking at least one glass of wine or other alcoholic beverage at bedtime

C, E Lying in bed when one is unable to sleep increases frustration and anxiety and further impedes sleep; other activities, such as reading or watching television, should not be conducted in bed. Exercise during the day expends energy and promotes sleep at night; exercise too close to bedtime is stimulating and may interfere with sleep. A heavy meal exerts pressure against the diaphragm that may be uncomfortable and the body is expending energy to digest the food; a light, not heavy, snack is preferred before bedtime. The bed should be used exclusively for sleep so the client's body expects sleep when the client gets into bed. Although milk may promote sleep, coffee contains caffeine, which is a stimulant that should be avoided after midafternoon; otherwise, it may interfere with sleep. The client should avoid caffeine, nicotine, and alcohol at least 4 hours before bedtime.

What is the rationale for performing sponge, needle, and instrument counts in the operating room? A. The hospital is not liable if a client is injured due to a retained sponge or instrument. B. The nursing student is liable for client injuries due to a retained sponge or instrument. C. A nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. D. The primary healthcare provider is responsible for providing an accurate count of sponges and instruments.

C. A nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. A nurse should perform sponge and instrument counts in the operating room as part of routine surgical standards to help prevent injuries and lawsuits. If a client suffers from an injury due to a retained sponge or instrument, the hospital is liable if the nurse had recorded an accurate count. A nursing student is not allowed to perform vital tasks such as counting sponges and instruments in the operating room. Even though the primary healthcare provider may insert sponges and instruments in a client, the provider relies on the nurse to maintain an accurate count at the end of the procedure.

The registered nurse asked the student nurse to care for a client whose dermal-epidermal junction is flattened. On assessing the client, the registered nurse observes that the risk for skin tears is increased. Which action of the student nurse may have resulted in this condition? A. Taping the client's skin B. Encouraging the client to take vitamin D supplements C. Assisting the client to change positions at 4-hour intervals D. Avoiding the removal of the client's adhesive wound dressings

C. Assisting the client to change positions at 4-hour intervals The nurse should assist a client who has flattening of the dermal-epidermal junction and is confined to a bed or wheelchair to change position at least every 2 hours. Changing the position of the client at 4-hour intervals may have raised the risk of skin tears. Taping the client's skin may result in increased transparency and fragility. Clients are encouraged to take vitamin D supplements to reduce the risk of osteomalacia. The client's adhesive wound dressing should be carefully removed to prevent the risk of skin tears.

The nurse is caring for a couple who have just received amniocentesis results indicating that their fetus has trisomy 18. Why is it important for a nurse to support the parents' decision to abort a fetus with a birth defect even if the nurse is morally opposed to abortion? A. Supporting them will eliminate feelings of guilt. B. The parents are legally responsible for the decision. C. It is important for maintenance of the family equilibrium. D. The nurse's support will relieve the pressure caused by this decision.

C. It is important for maintenance of the family equilibrium. Although support may help minimize guilt and feelings of pressure, it will not eliminate it; however, support will sustain family cohesion and unity. Support does not affect the legal responsibility of the parents.

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? A. Emptying the unit is safer when it is half full. B. Accurate measurement of drainage is facilitated. C. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. D. Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound.

C. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. As drainage collects and occupies space, the original level of negative pressure decreases; the less the negative pressure, the less effective the drainage. A portable wound suction device is easy and safe to empty regardless of the amount of drainage in the unit. Drainage can be measured accurately by the calibrations on the unit or in a calibrated container after emptying. A one-way valve between the tubing and the collection chamber prevents drainage from entering the tubing and causing trauma to the wound.

An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have? A. Laryngeal trauma B. Vocal cord paralysis C. Obstructive sleep apnea D. Subcutaneous emphysema

C. Obstructive sleep apnea Obstructive sleep apnea (OSA) is a condition in which the client may feel tired upon waking in the morning and may feel sleepy during the daytime. These clients may also snore heavily while sleeping. Smoking and enlarged tonsils increase the risk of sleep apnea. Laryngeal trauma occurs secondary to a crushing or direct blow injury, fracture, or prolonged endotracheal intubation. Vocal cord paralysis occurs in clients with neurologic disorders or with conditions that damage either the vagus nerve or the laryngeal nerves. Subcutaneous emphysema is a manifestation of laryngeal trauma, a condition in which there is the presence of air in the subcutaneous tissue.

A registered nurse is teaching a student nurse about factors that influence sleep. Which scenario explained by the registered nurse is an example of a lifestyle factor? A. "A client complains of trouble falling asleep because he or she is thinking about stress at work." B. "A client in the intensive care unit says he or she has not been able to sleep properly because of noises and disturbances." C. "A client who has been taking antidepressants complains of excess drowsiness and lack of sleep." D. "A client who works irregular rotating overnight shifts complains of difficulty sleeping through the night and fatigue."

D. "A client who works irregular rotating overnight shifts complains of difficulty sleeping through the night and fatigue." An individual's lifestyle can influence his or her sleep patterns. Working irregular rotating overnight shifts will throw off a client's biological clock, disrupting sleep.

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. What is the best response by the nurse? A. "That client is not on our unit. Thank you for calling." B. "The new privacy laws prevent me from providing any client information over the phone." C. "The client has requested that no information be given out. You'll need to call the client directly." D. "It is against the hospital's policy to provide you with any information."

D. "It is against the hospital's policy to provide you with any information." The response "It is against the hospital's policy to provide you with any information." is a factual statement, without indicating whether or not the client is in the hospital. The response "That client is not on our unit. Thank you for calling." is a lie and should be avoided. HIPAA (Canada: FOIPOP) laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others.

A client with a diagnosis of antisocial personality disorder is being discharged from the hospital. The client asks the nurse, "Can I have your phone number so I can call you for a date?" What is the best response by the nurse? A. "We are not permitted to date clients." B. "It is against my professional ethics to date clients." C. "I'm glad you like me, but I can't give out my phone number." D. "Our relationship is professional; therefore I will not see you socially."

D. "Our relationship is professional; therefore I will not see you socially." Stating "Our relationship is professional; therefore I will not see you socially" sets clear limits on the relationship and maintains a professional rather than a social role. Saying "We are not permitted to date clients" shifts responsibility from the issue at hand to the institution. Stating "It is against my professional ethics to date clients" avoids the real issue and shifts responsibility to the ethical code. Saying "I'm glad you like me, but I can't give out my phone number" does not clarify the nature of the relationship as professional.

A nurse manager promotes a staff nurse to assistant manager of the medical unit as the staff nurse had expressed interest in taking on more responsibilities. Which type of ethical principle is exhibited by the nurse manager by this activity? A. Fidelity B. Autonomy C. Paternalism D. Beneficence

D. Beneficence According to ethical principles, beneficence states that the actions one takes should promote good; it is the basic obligation to assist others. Therefore, by employing this principle, the nurse manager as a leader is encouraging employees to seek more challenges in clinical experiences and to take on additional responsibilities. Fidelity means fulfilling the promises or commitments made to others. Autonomy is the activity of addressing personal freedom and self-determination. Paternalism may be used to assist people in making decisions when they do not have sufficient data or expertise.

The nurse is caring for a client who underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely from what? A. A normal response to the analgesic B. Oral dryness caused by nasal packing C. An adverse reaction to anesthesia D. Bleeding posterior to the nasal packing

D. Bleeding posterior to the nasal packing Frequent swallowing may indicate bleeding in the posterior pharynx. Oral dryness causes thirst, not an increase in swallowing. Frequent swallowing is not a normal response to rhinoplasty or analgesics, nor is it an abnormal response to anesthesia.

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? A. A column of water 20 cm high in the suction control chamber B. 75 mL of bright red blood in the drainage collection chamber C. An intact occlusive dressing at the insertion site D. Constant bubbling in the water seal chamber

D. Constant bubbling in the water seal chamber Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and therefore the healthcare provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.

What principle must a nurse consider when caring for a client with a closed wound drainage system? A. Gravity causes fluids to flow down a pressure gradient. B. Fluid flow rate is determined by the diameter of the lumen. C. Siphoning causes fluids to flow from one level to a lower level. D. Fluids flow from an area of higher pressure to one of lower pressure.

D. Fluids flow from an area of higher pressure to one of lower pressure. A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device. Newton's law of gravity is not the physical principle underlying the functioning of a portable wound drainage system. Although fluid flow rate is determined by the diameter of the lumen and siphoning causes fluids to flow from one level to a lower level, they are not what cause the fluid to drain in a portable wound drainage system.

A child admitted to the hospital is in need of a life-saving heart transplant surgery. However, the parents refuse to allow the surgery stating that such surgeries are against their belief system. The nurse in charge of the client recognizes the situation as an ethical dilemma. What first step should the nurse take in order to resolve the dilemma? A. Evaluate the outcome of the plan of action over time. B. Verbalize the problem and agree to a statement as a group. C. Examine his or her own values critically to formulate an opinion about the issue. D. Obtain information from the child, the parents, health care workers, and other sources.

D. Obtain information from the child, the parents, health care workers, and other sources. After determining that an ethical dilemma exists in a situation, the nurse should focus on gathering information from multiple sources. The perspectives obtained from the child, the parents, health care workers, and other sources are helpful because it is essential to incorporate as much knowledge as possible. Evaluating the outcome of the plan of action over time is the last step of resolving an ethical dilemma. After gathering all relevant information regarding the issue and clarifying values, it is essential to verbalize the problem. A group agrees on a simple problem statement in order to hold a discussion on an issue. After gathering relevant information regarding the ethical dilemma, the nurse should examine his or her own values critically in order formulate an opinion regarding the matter.

A client in need of a lung transplant tells the nurse, "I will not take the organ of any person belonging to a different religion." The nurse initiates the process for resolving the ethical dilemma by collaborating with other healthcare team members. What should the team do after agreeing to a statement of the problem? A. The team should interview the family members of the client. B. The team should initiate negotiations for the appropriate course of action. C. The team should assess whether the client is satisfied with the course of action taken. D. The team should determine all the possible courses of action based on available information.

D. The team should determine all the possible courses of action based on available information. When resolving an ethical dilemma, the healthcare team should determine all possible courses of action after agreeing to a statement of the problem. At this stage the members of the team weigh all the possible options to address the situation. The team should interview the family members of the client to gather relevant information related to the situation. However, this step is performed immediately after deciding that the problem is an ethical dilemma. The team members may negotiate a plan after determining all the possible courses of action to address the ethical issue. After resolving an ethical dilemma, the last step is to evaluate the action and the level of success. The team members may assess whether the client is satisfied with the course of action taken, at this stage.