Compass Exam 5

The nurse enters a client's room to administer a medication that has been prescribed by the primary health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate? 1.) "It's called furosemide, and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet." 2.) "It's to help get rid of the swelling in your feet." 3.) "I know that it's for fluid buildup, and I think you've taken it before." 4.) "You need to discuss this medication with your physician."

1 Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Therefore, the appropriate response is the one that is thorough and complete. Referring the client to the primary health care provider places the client's question on hold. The remaining options are incomplete.Test-Taking Strategy: Focus on the subject, answering a client's question about a medication. Note the strategic word "appropriate." Eliminate the option that refers the client to the physician, because it places the client's question on hold. To select from the remaining choices, find the option that is most complete and thorough.Review: client rights Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Ethical/LegalGiddens Concepts: Client Education, Health Care LawHESI Concepts: Health Policy/Systems—Health Care Law, Teaching and Learning/Client Education

A nurse is planning the client assignments for the shift. Which client is most appropriate for the nurse to assign to the nursing assistant? 1.) A client with diarrhea on whom contact precautions have been imposed 2.) A client with a draining abdominal wound that requires frequent dressing changes 3.) A client who needs a blood transfusion 4.) A client with angina who needs to be ambulated for the first time since admission

1 Rationale: A client under contact precautions is the most appropriate assignment for the nursing assistant because the nursing assistant is trained to provide hygiene care and to care for clients under specific precautions. Assignment of tasks must be based on the job description of the nursing assistant, the assistant's level of clinical competence, and state law. Blood transfusions, dressing changes, and ambulation of a client with angina require the skill of a licensed nurse.Test-Taking Strategy: Focus on the subject, assigning a client to the nursing assistant. Note the strategic words "most appropriate". This indicates the best client to assign to the nursing assistant. Think about knowledge regarding tasks that may be safely delegated to the nursing assistant. Read each client description and think about the needs of the client. Recalling that clients requiring invasive procedures or close monitoring must be assigned to a licensed nurse will assist you in answering correctly.Review: delegation and assignment-makingLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgemnt, CaregivingHESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Malong-ClinicalJudgment-Critical thinking

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up? Select all that apply. 1.) A client with a central venous catheter has a temperature of 100.6° F (38.1°C). 2.) A client who has just undergone surgery is getting relief from the prescribed pain medication. 3.) A client with a new diagnosis of diabetes mellitus is self-administering insulin. 4.) A client is performing his/her own colostomy irrigations. 5.) A client who has just undergone surgery has a urine output of more than 30 mL/hr.

1 Rationale: A temperature of 100.6° F (38.1°C) in a client with a central venous catheter is an unexpected and unwanted outcome requiring the need for follow-up, because it may indicate the development of an infection. A case manager is a nurse who assumes responsibility for coordinating a client's care from the point of admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. The other options all represent expected outcomes.Test-Taking Strategy: Think about the role of the case manager and read each client description carefully. Next, focus on the subject, an unexpected outcome and the strategic words "need for follow-up". This indicates a negative event query and will direct you to the outcome that is unexpected or unwanted. An increased temperature is a concern because it is a sign of infection.Review: dealing with unexpected outcomes Level of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/EvaluationContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, Care CoordinationHESI Concepts: Professional Behaviors-Professionalism, Collaboration/Managing Care

The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the primary health care provider. The primary health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first? 1.) Inform the primary health care provider that removal of a chest tube is not a nursing procedure 2.) Explain the procedure to the client, then remove the chest tube 3.) Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube 4.) Call the nursing supervisor

1 Rationale: Actual removal of a chest tube is the duty of a primary health care provider. Therefore, the nurse would first inform the primary health care provider that this is not a nursing procedure. If the primary health care provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agency's policies and procedures may permit an advanced practice nurse (a nurse with a master's degree in a specialized area of nursing) to remove a chest tube. However, there is no information in the question to indicate that the nurse is an advanced practice nurse.Test-Taking Strategy: Focus on the subject, nurse asked to remove a chest tube. Eliminate the options that are comparable or alike in that they indicate that the nurse would remove the chest tube. To select from the remaining options, note the strategic word "first." The nurse should discuss the prescription with the physician.Review: chest tubes Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Health Care Policy, SafetyHESI Concepts: Health Policy/Systems—Health Care Policy, Safety

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? 1.) Occupational therapy 2.) Physical therapy 3.) Social services 4.) Home care

1 Rationale: An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding him- or herself with the use of an adaptive device. Home care provides a variety of support services for the client and family, but the specific assistance needed for this client would be provided by the occupational therapist. A social worker is trained to counsel clients in a variety of areas and may assist with the financial aspects of care. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques.Test-Taking Strategy: Focus on the subject, the need for assistance in eating. Recalling the functions and roles of the occupational therapist and the other healthcare workers in the options will help you answer correctly.Review: referrals Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Halth Care QualityHESI Concepts: Professional Behaviors-Professionaism, Clinical Decision Making-Clinical Judgment-Critical Thinking

The nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which action is the most appropriate for the nurse to take? 1.) Report the incident to the nursing supervisor 2.) Tell the client that the nurse did the right thing in giving the enema 3.) Contact the client's primary health care provider 4.) Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery

1 Rationale: Battery is any intentional touching of a client without the client's consent. Such contact may be harmful to the client or it may merely be offensive to the client's dignity. If a nurse discovers that battery of a client has occurred, the nurse should report the situation to the nursing supervisor. Telling the client that the nurse did the right thing in giving the enema is incorrect, because the other nurse has violated the client's rights. Confronting the nurse and telling her that she is going to be charged with battery would likely result in unnecessary conflict. Although the primary health care provider may need to be notified, the nurse should first report the situation to the nursing supervisor.Test-Taking Strategy: Focus on the subject, client rights,and note the strategic words"most appropriate." Recalling that any situation that constitutes a violation of a client's rights needs to be reported and remembering the organizational channels of reporting will direct you to the correct option.Review: batteryLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Elimination, Health Care LawHESI Concepts: Elimination, Health Policy/Systems—Health Care Law

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, what is the priority action by the nurse? 1.) Administer cardiopulmonary resuscitation (CPR) 2.) Contact the client's next-of-kin 3.) Call the client's primary health care provider 4.) Contact the nursing supervisor for directions

1 Rationale: CPR is an emergency treatment that is provided without client consent unless a DNR order is part of the client's record. Calling the client's next-of-kin, contacting the nursing supervisor for directions, and calling the primary health care provider are all inappropriate actions that would delay necessary treatment.Test-Taking Strategy: Focus on the subject, 97 year old client who is not breating and who does not have a DNR order. Eliminate the options that are comparable or alike in that they delay necessary treatment.Review: CPR and DNRLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Ethics, Health Care LawHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors-Professionalism

A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is "uncooperative and a real pain to care for." What is the most appropriate way the nurse leader would manage this issue? 1.) Discourage the judgmental comments 2.) Ignore the comments made about the client 3.) Leave articles about judgmental opinions in the nurses' report room 4.) Report the nurses' comments to administration

1 Rationale: Discouraging judgmental comments is the most appropriate way for the nurse leader to manage this concern.Nurses must discuss clients in a professional manner and avoid using judgmental language such as "uncooperative" or "difficult." When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not addressed. Leaving articles about judgmental opinions in the nurse's report room indirectly addresses the issue. Additionally, the nurse manager cannot ensure that the nursing staff will read the articles. Likewise, reporting the nurses' comments to administration does not directly address the issue. The best approach that the nurse manager can take is to directly discuss the issue with the staff members. This action is not identified in the options.Test-Taking Strategy: Focus on the subject, nurse leader dealing with judgmental comments made by staff. Note the strategic words "most appropriate". This indicates the best way for the nurse leader to deal with the situation. Eliminate the options that are comparable or alike in that they do not directly address the staff's unprofessional behavior.Review: judgmental commentsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, LeadershipHESI Concepts: Professional Behaviors-Professionalism, Communication

Which action exemplifies the use of evidence-based practice in the delivery of client care? 1.) Donning sterile gloves to change an abdominal wound dressing 2.) Taking a rectal temperature from a client for whom bleeding precautions have been instituted 3.) Advising a client to agree to the treatment recommended by her primary health care provider 4.) Encouraging a client to take an herbal substance to treat his insomnia

1 Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidence-based practice, because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted.Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note the strategic words "sterile gloves" in the correct option.Review: evidence-based practiceLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/Management Giddens Concepts: Evidence, SafetyHESI Concepts: Evidence-Based Practice/Evidence, Safety

A client with diabetes mellitus is being seen in the outpatient clinic. The client takes a daily dose of NPH insulin and is having a hard time drawing the insulin into a syringe because of difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral? 1.) Home care 2.) Social services 3.) Occupational therapy 4.) Physical therapy

1 Rationale: Home care provides a variety of support services for the client and family, including assistance with the administration of insulin. For the client who has difficulty drawing insulin into a syringe, the home care nurse would prefill a week's supply of syringes containing the required dose. These syringes would be placed in the client's refrigerator for self-administration by the client. A social worker is trained to counsel clients in a variety of areas and may assist with the financial aspects of care. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques. An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding him- or herself with the use of an adaptive device.Test-Taking Strategy: Focus on the subject, the need for assistance with insulin administration. Recalling the functions and roles of the home care nurse and the healthcare workers in the other options will help you answer correctly.Review: referrals Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Care CoordinationHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing Care

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client's deltoid muscle. What action by the LPN helps the RN to determine that the LPN is performing the procedure correctly? 1.) Administers the injection 2 inches (5 cm) below the acromion process 2.) Positions the client in a prone toe-in position 3.) Places the client in the Sims position 4.) Administers the injection in the thigh

1 Rationale: The RN is responsible for supervising certain procedures performed by an LPN to ensure that client safety is maintained. The deltoid muscle is located in the upper arm area. Administration of an injection into this muscle is done 2 inches (5 cm) below the acromion process (the bony structure on top of the shoulder blade). Therefore the injection is not given in the thigh (vastus lateralis or rectus femoris muscle). The Sims position is not the correct position for an injection into the deltoid muscle. A prone toe-in position is used for injection into the dorsogluteal site or gluteus medius muscle because it will promote internal rotation of the hips, which relaxes the muscle and makes the injection less painful.Test-Taking Strategy: Note the strategic words "deltoid muscle." Visualize each description in the options and use your knowledge of the anatomical locations of the various muscles to find the correct option.Review: IM injection into deltoid muscleLevel of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/EvaluationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Assessment, Safety

An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first? 1.) Peripheral pulses 2.) Radial pulse rate 3.) Heart rate 4.) Blood pressure (BP)

1 Rationale: The client who has sustained circumferential burns to the extremities is at risk for altered peripheral circulation. The first or priority assessment is for the nure to check the peripheral pulses to ensure that circulation is adequate. Although the heart rate and BP would also be assessed, the priority with a circumferential extremity burn is the assessment of peripheral pulses.Test-Taking Strategy: Focus on the subject, the nurse's first assessment on a client with a circumferential burns to the extremities. Eliminate the options that are comparable or alike first (heart rate and radial pulse rate). To select from the remaining options, focus on the strategic words "first" and "circumferential burns of both legs." Assessing peripheral pulses are the priority assessment in a client who has sustained a circumferential burn of an extremity.Review: bilateral circumferential burns of extremities. Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ Assessment Content Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Nursing Interventions

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. What is the most appropriateaction the nurse can take? 1.) Ask the nurse manager of the intensive care unit (ICU) to discuss the assignment 2.) Return to the medical care unit and discuss the assignment with the nurse manager on that unit 3.) Refuse to do the assignment 4.) Tell the nurse manager to call the nursing supervisor

1 Rationale: The most appropriate action the nurse can take is to talk to the ICU nurse manager to discuss the assignment. This will help the nurse identify the rationale for the assignment or determine whether the assignment is actually more difficult. A nurse would not refuse an assignment. The nurse would not return to the medical care unit, which would constitute client abandonment. Additionally, this action does not address the conflict directly. Telling the nurse manager to call the nursing supervisor is an aggressive action that does not address the conflict directly.Test-Taking Strategy: Focus on the subject, dealing with conflict. Refusing to perform the assignment is unethical and could be grounds for dismissal. Leaving the nursing unit constitutes client abandonment and could also result in dismissal. From the remaining options, select the option in which the conflict is dealt with directly. Note the strategic words "most appropriate". This indicates the best way the nurse can deal with the situation.Review: dealing with conflictLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, CollaborationHESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Making-Clinical Judgment-Critical Thinking

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. What action by the new nursing graduate suggests to the nurse that the new nursing graduate needs assistance with time management? 1.) Documents task completion and client information at the end of the day 2.) Prioritizes client needs and daily tasks 3.) Gathers supplies before beginning a task 4.) Allows time for unexpected tasks

1 Rationale: The nurse should document task completion and client information throughout the day. Allowing time for unexpected tasks, prioritizing needs and tasks, and gathering supplies before beginning a task are all components of time management.Test-Taking Strategy: Note the strategic words "needs assistance." These words indicate a negative event query and the need to select the incorrect action by the nursing graduate. Read each option carefully and recall the guidelines for time management to answer the question.Review: time management Level of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Clinical Decision Malong-Clinical Judgment-Critical Thinking, Clinical Judgment, Adherence

A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (assistive personnel)? 1.) A client with renal calculi whose urine must be strained 2.) A client scheduled for a laparoscopic cholecystectomy 3.) A client scheduled for a cardiac stress test 4.) A client who had a mastectomy 2 days ago

1 Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. The nursing assistant has been trained to collect and strain urine. The nurse manager would provide instructions to the nursing assistant regarding the task, but the task is within the role description of a nursing assistant. A client scheduled for a cardiac stress test requires preparation for the test, teaching, and postprocedure monitoring. A client scheduled for surgery will require preoperative preparation, including teaching. A client who underwent mastectomy 2 days earlier will need both physiological and psychosocial care, requiring the skills of a licensed nurse.Test-Taking Strategy: Focus on the subject, client assigned to a nursing assistant. When asked questions related to delegation, think about the role description of the employee and the needs of the client. For the nursing assistant, select the client who has needs that are noninvasive and do not require a high level skill, meaning that assessment, teaching, and monitoring are inappropriate tasks.Review: delegation Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing Care

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? 1.) She will have to discuss the prescribed test with the client. 2.) She can read the client's medical record to determine what the primary health care provider prescribed. 3.) The radiology department is not clear as to which test has been prescribed. 4.) A bone scan is being performed.

1 Rationale: Unless a client consents, a nurse may not disclose confidential information to anyone else. Therefore the appropriate response is to tell the client's wife that she will have to discuss the test with the client. Likewise, a client's medical record is confidential and cannot be given to the wife for reading. Telling the client's wife that the radiology department is unclear as to what test has been prescribed is inappropriate. The nurse must not place the responsibility or accountability for a prescribed test on another department.Test-Taking Strategy: Focusing on the subject, confidentiality, and recalling the issues surrounding confidentiality will direct you to the correct option.Review: confidentialityLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Professional Identity, EthicsHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors-Professionalism

A primary health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the primary health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? 1.) Discussing the situation with the nurse manager 2.) Fulfilling the physician's request 3.) Reporting the primary health care provider to the chief of medicine at the hospital 4.) Stating to the physician, "I don't really care whether you report me. I am not writing your prescriptions."

1 Rationale: When a conflict arises, it is most appropriate to try resolving the conflict directly. In this situation, the nurse has tried to explain why she is uncomfortable with the physician's request but has been unable to resolve the conflict. The nurse would then most appropriately use organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the primary health care provider or seek assistance from the nursing supervisor. Fulfilling the physician's request and writing the prescriptions in the clients' charts ignores the issue. Reporting the primary health care provider to the chief of medicine is inappropriate, because the nurse should use the appropriate organizational channels of communication to resolve the conflict. Stating, "I don't care whether you report me. I am not writing your prescriptions" is an inappropriate statement and will result in further conflict between the nurse and physician.Test-Taking Strategy: Focus on the subject, dealing with conflict between a physician and staff member. First eliminate the option that ignores the subject. Next, eliminate the option that will result in further conflict between the nurse and physician. To select from the remaining options, think about the appropriate use of the organizational channels of communication; this will direct you to the correct option.Review: managing conflictLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, CommunicationHESI Concepts: Professional Behaviors-Professionalism, Communication

The charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriateaction for the charge nurse to take? 1.) Contact the nursing supervisor 2.) Ask the staff member how much alcohol she has consumed 3.) Tell the staff member that she is not allowed to administer medications 4.) Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off

1 Rationale: When a staff member reports to work in a state of alcohol intoxication, the nurse notes the signs/symptoms objectively and asks a second person to validate these observations. The nurse also contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are signs/symptoms of intoxication. Client safety is the primary concern. After contacting the nursing supervisor, the intoxicated nurse is removed from the situation, confronted briefly and firmly about the behavior, and sent home to rest and recuperate. The incident is recorded and the nurse describes the observations, states the action taken, indicates future plans, and has the staff member sign and date the memo of the recorded incident after returning to work. Refusal to sign and date the memo should be noted by the charge nurse and a witness. Neither asking the staff member to rest in the nurses' lounge until the effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to administer medications removes the staff member from the client care area, jeopardizing the client's safety. Asking the staff member how much alcohol he/she has consumed is confrontational and irrelevant.Test-Taking Strategy: Keep in mind that client safety is the priority. Asking the staff member how much alcohol he/she has consumed is irrelevant, so eliminate this option. Next eliminate the options that are comparable or alike in that they do not involve removal of the staff member from the client care area.Review: substance abuse in staff Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/Management Giddens Concepts: Health Care Policy, LeadershipHESI Concepts: Health Policy/Systems—Health Care Policy, Collaboration/Managing Care—Leadership

A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. What observed activity by the nursing assistant would lead the RN to conclude that the nursing assistant is performing the procedure incorrectly? 1.) Stands behind the client 2.) Positions the free hand on the client's shoulder 3.) Stands on the right side of the client 4.) Grasps the security belt in the midspine area of the small of the client's back

1 Rationale: When walking with a client, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the client's back. The nurse should position the free hand at the shoulder area so that the client may be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet.Test-Taking Strategy: Note the strategic word "incorrectly." This word indicates a negative event query and the need to select the unsafe action by the nursing assistant. Visualizing the action in each option will direct you to the unsafe and incorrect action.Review: ambulation of client with weaknessLevel of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, SafetyHESI Concepts: Assessment, Safety

A nurse is employed in a community hospital as a nurse manager. What does the nurse understand that in this position, the term authority most appropriately refers to? Select all that apply. 1.) Power of an individual to approve an action 2.) Ability to command an action 3.) The official power to see that an organizational decision is enforced 4.) Accepting the responsibility for the actions of others 5.) Carrying the legal responsibility for others' performance of tasks 6.) Being responsible for what staff members do

1,2,3 Rationale: The term authority most appropriately refers to the official power of an individual to approve or command an action or to see that a decision is enforced. Being responsible for what staff members do, accepting responsibility for the action of others, and carrying legal responsibility for others are not related to the description of a position of authority.Test-Taking Strategy: Focus on the subject, and knowledge regarding the descriptions of a position of authority. Note the strategic words most appropriately. This indicates those defnitions that best decribes authority. Note the relationship between the word "authority" in the question and "power" in the correct option. Also note that the incorrect options are comparable or alike in that they involve responsibility.Review: authorityLevel of Cognitive Ability:ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, LeadershipHESI Concepts: Professional Behaviors-Professionalism, Health Policy/Systems

The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse's new role? Select all that apply. 1.) Assessing the client's needs for home supplies and equipment 2.) Coordinating consultations and referrals to facilitate discharge 3.) Evaluating and updating the plan of care as needed 4.) Prescribing treatments specific to the client's needs 5.) Establishing a safe and cost-effective plan of care with the client

1,2,3,5 Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client's needs, taking into account the client's diagnosis, self-care ability, and prescribed treatments; assessing the client's need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments.Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the strategic word "prescribing" in the incorrect option. It is not within the role of the nurse to prescribe.Review: case management Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/Management Giddens Concepts: Care Coordination, LeadershipHESI Concepts: Collaboration/Managing Care—Care Coordination, Collaboration/Managing Care-Leadership

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. What does the nurse know that a DNR order means? Select all that apply. 1.) The DNR order requires frequent review as specified by state or agency policy 2.) The client is the responsible person who may change the DNR order. 3.) That it must be legally and ethically implemented. 4.) The DNR order, as written on admission, must remain in effect for the duration of the client's hospitalization 5.) The DNR order may be changed once it is in effect 6.) That CPR can be started but no medications can be administered.

1,2,3,5 Rationale: If the client's condition changes, the DNR order may need to be changed. For this reason, DNR orders require frequent review as specified by state or agency policy. A DNR order may be changed at any time and does not remain in effect for the duration of the client's hospitalization. The client's request regarding DNR status is the priority.Test-Taking Strategy: Focus on the subject, the conditions of a DNR order. Know that the DNR order does not have to remain in effect for the duration of the client's hospitalization. Also know that CPR as well as resuscitative medications should not be given if a DNR order is in place.Review: DNR Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Ethical/LegalGiddens Concepts: Ethics, Health Care LawHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors-Professionalism

A nurse is providing a change-of-shift report on his/her assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply. 1.) Current diagnosis and any secondary diagnoses 2.) Client response to treatments implemented that day 3.) Steps used to perform the procedure for changing the client's sterile dressing at the gastrostomy tube site 4.) Results of laboratory studies conducted that day 5.) Family history 6.) Client needs and priorities of care

1,2,4,6 Rationale: A change-of-shift report ensures continuity of care among nurses caring for a client and informs the nurse on the next shift about the client's needs and priorities for care. It may be given written, orally, by audiotape, or while the nurses are walking rounds at a client's bedside. The report should describe the client's health status, current and secondary diagnoses, results of laboratory or diagnostic studies done that day, and the client's response to treatments implemented that day. The client's family history does not need to be described in a change-of shift report, and doing so would take time. If such information is needed by the oncoming nurse, it may be obtained from the client's medical record. There is no useful reason for describing a routine procedure; this would also take time, and the information is available in the agency procedure manual.Test-Taking Strategy: Focus on the subject, what to include in the change-of-shift report. Read each option carefully and eliminate family history, because it is not directly related to the client's current status. Next eliminate the option that involves describing the steps in performing a procedure, because this is routine information. Also note that the correct options are client focused.Review: change-of-shift reportLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, CommunicationHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Communication

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (assistive personnel)? Select all that apply. 1.) A client who requires transport to the radiology department in a wheelchair 2.) A client requiring a gastrostomy tube dressing change 3.) A client with a Foley catheter for whom a 24-hour urine collection is in progress 4.) A client with a permanent tracheostomy 5.) A client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter

1,3 Rationale: The nurse must base assignments on the basis of the skills of the staff member and the needs of the client. The nursing assistant is capable of caring for the client with a Foley catheter for whom a 24-hour urine collection is in progress and the client who requires transport to the radiology department in a wheelchair. The nursing assistant is skilled in such tasks. The client who has just undergone surgery will require specific monitoring in addition to recording of vital signs. Dressing changes and tracheostomy care are not performed by unlicensed personnel.Test-Taking Strategy: Focus on the subject, assignments for the nursing assistant. Think about the skills that the nursing assistant can perform and remember that the nursing assistant may perform tasks that are noninvasive.Review: delegation Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Quality Improvement-Health Care Quality

A new nurse employed at a community hospital is reading the organization's mission statement. What statements suggest that the new nurse understands what the organization's mission is? Select all that apply. 1.) Includes the organization's purpose, goals or objectives 2.) Identifies the policies and procedures of the organization 3.) Defines the rules of the organization that the employees must follow 4.) Describes the benefits available to employees 5.) Incorporates statements of philosophy (beliefs) 6.) Outlines what the organization plans to accomplish

1,5,6 Rationale: All organizations have a purpose or reason for existing. This purpose is often expressed in the form of a mission statement. The mission statement outlines what the organization plans to accomplish. Sometimes mission statements incorporate statements of philosophy (beliefs), purpose, and goals or objectives into a single statement; other times the philosophy, purposes, and goals are addressed in addition to the mission statement. These statements serve as a benchmark against which an organization's performance may be evaluated. The mission statement does not describe the benefits available to the client; this is usually done by the human resources department. The rules of the organization are identified in policies and procedures, which are usually maintained in manuals kept in the nursing units or online.Test-Taking Strategy: Use the process of elimination, focusing on the subject, a mission statement. Note the relationship between the definitions of a mission statement and the correct options.Review: mission statementCognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Communication, Health Policy/Systems

A nurse is reading the nurse practice act for the state in which he/she is employed. How does the nurse use the information in this act? 1.) Know how to perform certain procedures 2.) Be aware of the role of the professional nurse 3.) Be aware of hospital and long-term care facilities policies 4.) Identify healthcare policies in her state

2 Rationale: A nurse practice act regulates the licensure and practice of nursing. Nurse practice acts describe in general terms what constitutes nursing practice. Actions that are considered unprofessional conduct are usually identified. Guidelines for procedures and policies are formulated by the specific healthcare agency. The healthcare policies of the state in question are not identified in a nurse practice act.Test-Taking Strategy: Focus on the subject, Nurse Practice Act. Note the relationship between the words "nurse practice act" in the question and "role of the professional nurse" in the correct option.Review: nurse practice act Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Professional Identity, Health QualityHESI Concepts: Professional Behaviors-Professionism, Quality Improvement-Health Care Quality

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by taking which action? 1.) Noting in the client's record that the client was not told about the risks of the surgery 2.) Calling the surgeon and asking that the risks be explained to the client 3.) Reassuring the client that the risks are minimal 4.) Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room

2 Rationale: A nurse serves as a client advocate by protecting the right of the client to be informed and to participate in decisions regarding care. The only option that ensures that the client will be informed of the risks of the surgery is contacting the surgeon and asking that the risks be explained to the client. Telling the client that the risks are minimal is false reassurance. Putting a note on the client's chart or documenting that the client was not informed about the risks does not ensure that the client will be informed.Test-Taking Strategy: Focus on the subject, the guidelines and principles of obtaining informed consent. Focusing on the strategic words "never told about the risks of the surgery" will direct you to the correct option, the only option that ensures that the client will be told about the risks.Review: advocacyLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Health Care Policy, SafetyHESI Concepts: Health Policy/Systems—Health Care Policy, Safety

A nurse is assigned to care for four clients. Which client should the nurse assess first? 1.) A client scheduled for a colonoscopy 2.) A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask 3.) A client preparing for discharge after surgery 4.) A client requiring a tube feeding through a gastrostomy tube

2 Rationale: Airway is always the priority, so the nurse would attend to the client who has a condition related to airway first. The other clients do not have conditions related to the airway and represent intermediate priorities.Test-Taking Strategy: Use the ABCs — airway, breathing, and circulation — to answer the question. The client with a tracheostomy is the only client with an airway problem. Note the strategic word "first". Remember that airway is always the first priority.Review: prioritizationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Assessment

The nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, "The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection." Which statement accurately describes the nurse's response to the client? 1.) The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. 2.) The nurse could be charged with assault. 3.) The nurse could be charged with battery. 4.) The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the physician.

2 Rationale: Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client's consent, the nurse may be charged with assault. Therefore, the nurse is not justified in administering the medication. Battery is any intentional touching without the client's consent.Test-Taking Strategy: Focus on the data in the question and the nurse's statement. Note that the nurse threatens the client. Next, recall the definition of assault, which will direct you to the correct option.Review: client rightsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Health Care Law, InfectionHESI Concepts: Health Policy/Systems—Health Care Law, Infection

Which action by the nurse represents the ethical principle of beneficence? 1.) The nurse upholds a client's decision to refuse chemotherapy for lung cancer. 2.) The nurse administers an immunization to a child even though it may cause discomfort. 3.) The nurse follows a plan of care designed to relieve pain in a client with cancer. 4.) The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.

2 Rationale: Beneficence is taking action to help others. Although administration of a child's immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person's independence. Respecting another's autonomy means that you are agreeing to respect that person's right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients.Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option.Review: Beneficence Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Ethics, ImmunityHESI Concepts: Advocacy/Ethical/Legal Issues, Immunity

A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member? 1.) A client with metastatic cancer who is receiving a continuous infusion of intravenous morphine sulfate 2.) A client with a solid sealed cervical radiation implant 3.) A client with diarrhea for whom enteric precautions are in effect 4.) A client for whom contact precautions have been implemented and who requires frequent wound irrigations

2 Rationale: Brachytherapy involves the implantation of a sealed radiation source within the targeted tumor tissue. A client who is wearing a solid implant emits radiation as long as the implant is in place; however, the client's excreta is not radioactive. Pregnant nurses should not care for such clients. There are no contraindications to having a pregnant nurse care for a client under enteric precautions, a client with cancer who is receiving a continuous infusion of intravenous therapy, or a client who requires frequent wound irrigation.Test-Taking Strategy: Focus on the subject, client not to be assigned to a pregnant nurse. Use the process of elimination, noting the strategic word "avoids." This word indicates a negative event query and the need to select the client situation that could present a risk to a pregnant client. Thinking about the risks associated with each client listed in the options will direct you to the correct one.Review: sealed radiation implantLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, SafetyHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety

A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that he/she will not work the overtime if he/she has made other plans after his/her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict? 1.) Avoiding assigning the nurse mandatory overtime 2.) Confronting the nurse regarding his/her behavior regarding the overtime policy 3.) Providing a positive reward system for the nurse so that the nurse will agree to work the mandatory overtime 4.) Ignoring the complaints

2 Rationale: Confrontation is an important strategy for addressing resistance by a staff member who is complaining about an agency protocol. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings and identification of problems and issues, and give the nurse manager the opportunity to develop strategies to solve the problem. Ignoring the complaints and avoiding assigning the nurse mandatory overtime are inappropriate strategies that do not address the problem. Providing a positive reward system might provide a temporary solution to the resistance but will not specifically address the problem.Test-Taking Strategy: Note the strategic word "best" in the query of the question and focus on the subject, dealing with conflict. Eliminate the options that ignore the nurse's complaints. To select from the remaining options, look for the option that specifically addresses the subject and provides problem-solving measures.Review: dealing with conflictLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, CommunicationHESI Concepts: Communication, Clinical Decision Making-Clinical Judgment-Critical Thinking

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client? 1.) Placing the client in a semiprivate room with a cohort client 2.) Keeping the door to the client's room closed 3.) Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times 4.) Using a surgical mask when entering the client's room

2 Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. Pulmonary tuberculosis is a respiratory infection that is transmitted to others by way of the airborne route. The door to the client's room must be kept closed to prevent the transmission of the infection via the airborne route. The remaining options do not reflect evidence-based practice. An N95 or HEPA respirator (not a surgical mask) must be worn by the nurse on entering the room. It is not necessary for the client to wear a mask. Airborne precautions require the use of a private room.Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and recall that tuberculosis is transmitted by way of the airborne route. This will direct you to the correct option.Review: evidence-based practiceLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Leadership/ManagementGiddens Concepts: Evidence, Health Care QualityHESI Concepts: Evidence Based Practice-Evidence, Nursing Interventions

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first? 1.) Clamp the chest tube with a Kelly clamp 2.) Submerge the end of the chest tube in a bottle of sterile water 3.) Call the primary health care provider 4.) Instruct the client to inhale and hold his breath

2 Rationale: If the tube becomes disconnected, the first action is to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. The primary health care provider must be notified, but this is not the first action. The client would not be instructed to inhale, because this would cause atmospheric air to enter the pleural space. In most situations, clamping of chest tubes is contraindicated. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax, because the air has no escape route.Test-Taking Strategy: Focus on the subject, chest tube disconnected. Use the process of elimination, noting the strategic word "first." Thinking about the principles related to a chest tube drainage system will direct you to the correct option. Remember that if the tube is disconnected the water seal must be reestablished.Review: closed chest tube drainage systemLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, SafetyHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety

An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client's parents but is unsuccessful. What does the nurse do in regard to informed consent for the surgery? 1.) The nurse will sign informed consent on behalf of the client and ask another nurse to witness the signature 2.) The nurse understands that consent is not needed 3.) The nurse will prepare the client to undergo mechanical ventilation until the client's parents can be contacted 4.) The nurse will contact the hospital clergy to provide informed consent

2 Rationale: In an emergency situation, if it is impossible to obtain consent from the client or an authorized person, the procedure required to benefit the client or save his or her life may be undertaken without informed consent. In such cases the law assumes that the client would wish to be treated. Contacting the hospital clergy to provide the informed consent and having the nurse sign on behalf of the client with another nurse to witness the signature are both incorrect. Also, having the client undergo mechanical ventilation until his parents can be contacted will delay treatment of a life-threatening injury.Test-Taking Strategy: Focus on the subject, informed consent for a client with a life-threatening injury. Note the strategic words "life-threatening injuries". This will direct you to the correct option.Review: informed consentLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Clinical Judgment, Health Care LawHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Health Policy/Systems

A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation? 1.) Tell the nurse that it is inappropriate to report other nurses 2.) Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had his/her technique validated 3.) Inform the nurse who reported the occurrence that intravenous ports do not need to be cleaned with alcohol before medication administration 4.) Provide an in-service educational session on aseptic technique for everyone on the nursing unit

2 Rationale: Intravenous ports must be cleaned with alcohol (or another antiseptic as designated by agency policy) before access. The nurse manager should handle this problem directly with the nurse who is using incorrect technique by first reviewing the nurse's skills checklist to determine whether this skill has ever been performed by the nurse and validated. There is no information in the question to indicate that an in-service educational session is needed for everyone on the nursing unit. As a part of professional responsibility to maintain quality care, nurses are required to report instances of clinical incompetence.Test-Taking Strategy: Focus on the subject, dealing with an employee who might need a review of sterile technique. Know your knowledge of the principles of ensuring quality care for clients. Remember that it is best for the nurse manager to deal directly with the employee who is exhibiting unacceptable behavior.Review: clinical incompetenceLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, EvidenceHESI Concepts: Professional Behaviors-Professionalism, Communication

The nurse calls a primary health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The primary health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide but does not specify the route of administration. What is the appropriate action on the part of the nurse? 1.) Call the nursing supervisor for assistance in determining the route of administration 2.) Call the primary health care provider who gave the telephone prescription to clarify the prescription 3.) Administer the medication orally and clarifying the prescription once the primary health care provider has finished caring for the client in the emergency department 4.) Administer the medication intravenously, because this route is generally used for clients with CHF

2 Rationale: Telephone prescriptions involve a primary health care provider's dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription clearly and precisely to the physician. The nurse then writes the prescription on the physician's prescription sheet. Under no circumstances should the nurse try to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. The nurse must call the primary health care provider who gave the telephone prescription and clarify the prescription.Test-Taking Strategy: Focus on the subject, incomplete primary health care provider's prescription. Eliminate the options that are comparable or alike in that they indicate that the nurse should administer the medication without clarifying the physician's prescription.Review: telephone prescriptionsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Health Care Policy, SafetyHESI Concepts: Health Policy/Systems—Health Care Policy, Safety

A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, "I don't want a bath. I've been up all night, and I'm clean enough." The student reports the client's refusal to the nurse in charge. Which action by the nurse in charge is appropriate? 1.) Telling the client that the primary health care provider will be informed of the refusal of care 2.) Telling the nursing student to allow the client to rest 3.) Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it 4.) Telling the nursing student to give the client the bath anyway

2 Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate and represent violations of the client's rights. Telling the client that the primary health care provider will be informed of the refusal of care is a threatening action on the nurse's part.Test-Taking Strategy: Focus on the subject, client refusing a bed bath. Remember your knowledge of client rights and note the strategic word appropriate. This word refers to the best option. Eliminate the options that present a threat to the client or indicate that the bath will be given regardless of the client's wishes.Review: client rightsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Clinical Judgement, EthicsHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors-Professionalism

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. The nurse suspects early acute compartment syndrome. On the basis of these assessment findings, which action should the nurse take first? 1.) Check to see whether it is time for more pain medication 2.) Contact the primary health care provider 3.) Encourage the client to continue active range of motion exercises of the left arm 4.) Reassess the client in 30 minutes

2 Rationale: The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. The affected client also complains that pain during passive motion is greater than that during active motion. The nurse must notify the primary health care provider immediately. The other options are incorrect because they delay necessary interventions.Test-Taking Strategy: Focus on the assessment data presented in the question. Note the strategic word first. This indicates the most important action to be taken by the nurse. Recall that these signs/symptoms indicate early acute compartment syndrome. Remember, if this is suspected, the primary health care provider needs to be notified. Also note that the incorrect options are comparable or alike in that they delay necessary intervention.Review: early acute compartment syndromeLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, EvidenceHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Nursing Interventions

A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment? 1.) The RN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications. 2.) The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home. 3.) The LPN is assigned to provide discharge teaching about dressing changes and medications to a 35-year-old man. 4.) The LPN is assigned to care for a client with newly diagnosed diabetes mellitus who will need to be taught how to self-administer insulin.

2 Rationale: The client with newly diagnosed leukemia who has a newborn at home is likely to be in need of the skills of an RN in terms of both physiological and psychosocial needs, making this the best and most appropriate assignment. To determine what may and may not be delegated to the various co-workers, the RN making the assignment must take into account several factors: the level of care required by each client, both immediately and in the future; the competencies possessed by the co-workers; and the legal limitations on the practice of those co-workers. Self-administration of insulin and discharge instructions on dressing changes and medications require teaching, a professional responsibility that the RN may not delegate to anyone except another RN. Although the RN might care for a client being discharged, the question tells you that an LPN is available. The RN would be best used to care for the client with more critical or complicated needs. Assigning an RN to a client who is being discharged with no medications is, therefore, incorrect.Test-Taking Strategy: Focus on the subject, best assignment by the RN. Use the process of elimination, noting the strategic word "best." Eliminate the options in which the LPN is assigned to a client requiring teaching. To select from the remaining options, focus on each client and think about his or her actual and potential needs. The RN is best assigned to the client with physiological and psychosocial needs.Review: assignment-makingLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing Care

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager? 1.) "I'm not working overtime today." 2.) "I have plans after work and will not be able to work overtime." 3.) "You know how I hate to work overtime." 4.) "I will if you need me, but I am not happy about this."

2 Rationale: The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse responds aggressively by stating, "I'm not working overtime today" or "You know how I hate to work overtime." The statement "I will if you need me, but I am not happy about this" is a passive-aggressive response.Test-Taking Strategy: Use the process of elimination, focusing on the subject, and note the strategic words "most assertive" response. Note the relationship between the data in the question and the correct option.Review: assertive communicationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Leadership/ManagementGiddens Concepts: Mood and Affect, CommunicationHESI Concepts: Behaviors, Communication

A primary health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The primary health care provider tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond? 1.) Telling the primary health care provider that if the client stops breathing, the primary health care provider will be called before any other actions are taken 2.) Telling the primary health care provider that "slow codes" are not acceptable 3.) Telling the primary health care provider that the client would probably want to die in peace 4.) Telling the primary health care provider that all of the nurses on the unit agree with this plan

2 Rationale: The nurse may not violate a family's request regarding the client's treatment plan. A "slow code" is not acceptable, and the nurse should state this to the physician. The definition of a "slow code" varies among healthcare facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are therefore inappropriate.Test-Taking Strategy: Focus on the information in the question — specifically, that the spouse will not grant permission for a DNR order. Recalling the procedures for CPR and the ethical/legal guidelines for a DNR order will direct you to the correct option. Review: terminal cancerLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Caregiving, EthicsHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Clinical Decision Making-Clinical Judgement-Critical Thinking

A primary health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the primary health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take? 1.) Continue to transcribe the prescription 2.) Contact the nursing supervisor 3.) Ask the nurse assigned to care for the client to administer the medication 4.) Verify the prescribed dose with the client before administering the medication

2 Rationale: The nurse must follow the primaary health care provider's prescription unless he or she believes that the prescription is in error or that it would harm the client. If a prescription is found to be incorrect or harmful, further clarification from the primary health care provider is necessary. If the primary health care provider confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact the nursing supervisor. The nurse should not continue transcribing the prescription or ask another nurse to implement the prescription. The nurse might ask the client about the medication and the dose taken at home but would not administer the medication.Test-Taking Strategy: Focus on the subject, primary health care provider who writes a prescription that is three times higher than the recommended dose. Eliminate the options that are comparable or alike in that they indicate that the medication would be administered.Review: primary health cae provider's prescriptionsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Ethics, SafetyHESI Concepts: Avocacy/Ethical/Legal Issues, Safety

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. What should the nurse do first before administering the medication? 1.) Check the client's apical pulse 2.) Check the placement of the tube 3.) Check when the last feeding was given 4.) Check when the last medications were given

2 Rationale: To help prevent aspiration, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Checking when a feeding or medication was last given and checking the client's apical pulse are not directly related to the subject of the question.Test-Taking Strategy: Focus on the subject, priority action by the nurse before administering medications by way of an NG tube. Note the strategic word "first." This indicates the priority action by the nurse. Use the ABCs — airway, breathing, and circulation. To help prevent the complication of aspiration when administering medications to a client with an NG tube, the nurse must first assess accurate placement of the tube.Review: medications through an NG tube Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ Assessment Content Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Assessment

A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act? 1.) Giving a verbal report to the nurse on the oncoming shift 2.) Using clean gloves to change a gastrostomy tube dressing 3.) Checking neurological signs/symptoms in a client with a head injury 4.) Contacting a primary health care provider about a change in a client's blood pressure

2 Rationale: Using clean gloves is a negligent act. The nurse should use sterile gloves to change a dressing over broken skin.Common negligent acts include medication errors that result in injury to the client; intravenous therapy errors resulting in infiltrations or phlebitis; burns caused by equipment, bathing, or spills of hot liquids and foods; falls resulting in an injury; failure to use aseptic technique where required; failure to give report or giving an incomplete report to an oncoming shift; failure to adequately monitor a client's condition; and failure to notify a primary health care provider of a significant change in a client's condition.Test-Taking Strategy: Focus on the subject, the nurse not following sterile techniqe. Note the strategic words "negligent act". This indicates a negative event query. Read each option carefully, and note the word "clean" in the correct option.Review: negligent actsLevel of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and Learning Content Area: Leadership/ManagementGiddens Concepts: Evidence, Health DisparitiesHESI Concepts: Nursing Interventions, Evidence Based Practice-Evidence

The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace? 1.) Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure 2.)Ask the client for permission to lock the necklace in the hospital safe 3.) Ask the client to remove the necklace and place it in the top drawer of the bedside table 4.) Ask the client whether the necklace is gold

2 Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most health care institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client's necklace. Valuables may be locked in a designated location such as the hospital's safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject.Test-Taking Strategy: Focus on the subject, safeguarding the client's necklace. Focusing on the subject and noting the word "lock" in the correct option will help you answer correctly.Review: client's valuablesLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Ethics, Health Care PolicyHESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care Policy

A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? 1.) A client who requires periodic suctioning 2.) A client who needs frequent ambulation with a walker 3.) A client who has undergone an arteriogram and requires close monitoring 4.) A client who needs a colostomy irrigation

2 Rationale: When a nurse delegates aspects of a client's care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. Noninvasive interventions such as ambulating a client with a walker may be assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy irrigation should be assigned to a licensed practical nurse (LPN) because these staff members can perform certain invasive procedures. The client who has undergone an arteriogram should be assigned to either an LPN or an RN because these personnel have the knowledge and education to detect changes in the client's status that require attention.Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment to a nursing assistant. Eliminate the options that are comparable or alike in that they involve invasive procedures. To select from the remaining options, think about the education that a nursing assistant receives. The nursing assistant is trained to ambulate a client with an assistive device but does not have the knowledge and education to assess and detect changes in a client's status.Review: delegationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking,Safety

A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem? 1.) Telling the employee that he/she will be fired if he/she calls in sick again 2.) Reminding the employee of the employment standards of the agency 3.) Documenting the employee's behavior in the personnel file 4.) Reporting the employee to administration

2 Rationale: When an employee demonstrates an unacceptable level of absenteeism, the nurse must first remind the employee of the employment standards of the agency. Sometimes an employee does not know or has forgotten the existing standards, and a reminder with no threats or discipline is all that is needed. When the oral reminder does not result in a change in behavior, the reminder should be placed in writing. If the written reminder fails, the employee should be granted a day of decision to determine whether to accept the standards for work attendance. Pay may be given for this day (depending on the agency protocol) so that it is not interpreted as punishment, and the employee must return to work with a written decision. If the employee decides not to adhere to standards, her employment with the agency is terminated. Reporting the employee to administration, documenting the employee's behavior in his/her personnel file, and telling the employee that she will be fired if she calls in sick again are not appropriate initial actions.Test-Taking Strategy: Focus on the subject, dealing with an employee who constantly calls in sick. Use the process of elimination, noting the strategic word "initially." Focusing on the data in the question and noting that there is no information to indicate that this employee has been approached about his or her behavior in the past will direct you to the correct option.Review: unacceptable staff behaviorLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, CommunicationHESI Concepts: Professional Behaviors-Professionalism, Communication

In which situation is the nurse upholding the ethical principle of fidelity? 1.) Providing complete information regarding treatment options to a client with newly diagnosed cancer 2.) Keeping promises made to clients. 3.) Contacting the primary health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan 4.) Providing complete information regarding treatment options to each client with a cancer diagnosis. 5.) Allowing a client to decide when to receive daily hygiene care 6.) Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion

2,3 Rationale: Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Contacting the primary health care provider about the client's request that complementary therapies be used to relieve pain is an example of fidelity. Respect for a person's autonomy, or independence, involves respecting that person's right to determine his or her own course of action. Allowing a client to decide when he or she would like to have daily hygiene care is an example of respecting a client's autonomy. Beneficence is taking action to help others. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion is an example of beneficence. Although insertion of an intravenous catheter might cause discomfort, the benefits of receiving the transfusion outweigh the temporary discomfort. Justice refers to fairness and equity; in the healthcare arena, this involves ensuring fair allocation of resources, such as nursing care, to all clients. Providing complete information regarding treatment options to each client with a cancer diagnosis is an example of justice.Test-Taking Strategy: Focus on the subject, definition of fidelity. Think about the definition of each item in the options. Note the relationship of the definition of fidelity and the correct options.Review: fidelity Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Ethics, LeadershipHESI Concepts: Professional Behaviors-Professionalism, Advocacy/Ethical/Legal Issues-Ethics

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply. 1.) Inform the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby 2.) Take the break in the staff lounge located on the nursing unit 3.) Conduct client rounds before taking the break 4.) Ask the nursing assistant to monitor a client's tube feeding and to contact the nurse when the feeding bag is empty 5.) Ask the nursing assistant to contact the primary health care provider during the nurse's break if a client's pain medication is not effective 6.) Ask the nursing assistant to administer a medication placed at the client's bedside if the client awakens

2,3 Rationale: The RN is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse's break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. A nursing assistant should never be asked to perform any activity that he or she is not trained for. This includes such activities as administering medications; assessing, monitoring, or evaluating the client; and making decisions about contacting a physician.Test-Taking Strategy: Think about the roles and responsibilities of the RN and the tasks or activities that the nursing assistant may legally perform and focus on the subject, safety. Remember that the registered nurse is responsible for administering medications; assessing, monitoring, and evaluating the client; and making decisions about contacting a physician.Review: delegationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety

A nurse, newly employed by a home health agency, is told that the organization's decision-making process is centralized. What does the nurse determine that the authority to make decisions is vested in? 1.) All nursing employees, pharmacists, and hospital physicians 2.) A narrower span of control 3.) A few individuals, such as the board of directors 4.) Decision-making authority concentrated in the top level of the hierarchy 5.) Every employee 6.) Many individuals, with decisions filtering down to the individual employee

2,3,4 Rationale: Organizations may be described as having a centralized or decentralized structure in regard to the decision-making process. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals, there is a narrower span of control and decision-making authority is concentrated in the top level of the hierarchy. Conversely, when the decision-making involves a number of individuals, with decisions filtering down to the individual employee, the organization is said to operate in a decentralized fashion.Test-Taking Strategy: Focus on the subject, an organization's centralized decion-making process. Eliminate the options that are comparable or alike in that they indicate that several people associated with the organization make decisions.Review: centralized and decentralized organizations Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Health Caré OrganizationsHESI Concepts: Clinical Decision Malong-Clinical Judgment-Critical Thinking, Health Policy/Systems

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply. 1.) "Accountability can be delegated." 2.) "It refers to the process of answering or being responsible for what occurs." 3.) "You are responsible for your own actions." 4.) "You are not responsible for the care that you ask others to complete." 5.) "It carries legal implications for task performance."

2,3,5 Rationale: Accountability, the process of answering or being responsible for what occurs, carries legal implications for task performance. Accountability cannot be delegated; one is responsible for one's own actions and must answer for the care given, as well as for the care one asks others to complete.Test-Taking Strategy: Focus on the subject, the definition of accountability. Recalling this definition will easily direct you to the correct options.Review: accountabilityLevel of Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Ethical/LegalGiddens Concepts: Professional Identity, EthicsHESI Concepts: Professional Behaviors-Professionalism, Advocacy/Ethical/Legal Issues-Ethics

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply. 1.) Are specific guidelines 2.) Are authoritative statements that describe a common level of performance 3.) Have some similarity to policies and procedures 4.) Are statements that relate only to the agency in which the nurse is employed 5.) Define professional practice 6.) Describe an acceptable level of client care

2,5,6 Rationale: Standards of care are authoritative statements that describe a common or acceptable level of client care or performance. They bear some similarity to policies and procedures. Therefore standards of care define professional practice. The American Nurses Association (ANA) has formulated general standards and guidelines for nursing practice. They are general in nature and apply across the nation.Test-Taking Strategy: Focus on the subject, standards of care formulated by the American Nurses Association. Note that the incorrect options are comparable or alike in that they contain the strategic words "specific", "similarity" or "only."Review: ANA standards of careLevel of Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Ethical/LegalGiddens Concepts: Communication, Health Care PolicyHESI Concepts: Communication, Advocacy/Ethical/Legal Issues-Ethics

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. What is the most appropriate action by the nurse? 1.) The primary health care provider makes the final decision about a DNR request 2.) Consent must be obtained from the family 3.) The DNR request should be discussed with the physician, who will write the order 4.) Oral consent is sufficient and that his request will be honored by all primary healthcare providers

3 Rationale: A client may request a DNR order after being given the appropriate information by the physician. Therefore, if a client requests a DNR order the nurse should contact the primary health care provider so that the primary health care provider may discuss the request with the client. A DNR order should be written, not verbal. The pertinent agency and state guidelines must be followed with regard to when a verbal DNR order is acceptable. Therefore the other options are incorrect.Test-Taking Strategy: Focus on the subject, client who requests a DNR order. Recall your knowledge of the issues related to DNR orders. Eliminate the options that contain the closed-ended words "must" and "all." Note the strategic words "most appropriate". This refers to the best option. Next, recall that the client has the right to request a DNR order, which will direct you to the correct option from those remaining.Review: DNR Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Ethics, LeadershipHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Health Policy/Systems

A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first? 1.) Removing some of the traction weights 2.) Asking the client to wiggle her toes 3.) Realigning the client 4.) Medicating the client with the prescribed analgesic

3 Rationale: A client who complains of severe pain may need realignment or may have traction weights that are too heavy. The nurse would first realign the client and then, if this is ineffective, call the primary health care provider. Asking the client to wiggle her toes serves no useful purpose. The nurse never removes traction weights unless this has been specifically prescribed by the primary health care provider. The client should be medicated only after an effort has been made to determine and treat the cause of her pain.Test-Taking Strategy: Focus on the subject, care of client in skeletal traction with complaints of pain in the leg. Note the strategic word "first." Recall the causes of pain in a client with skeletal traction and remember that the nurse first determines and treats the cause.Review: skeletal tractionLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Nursing Interventions

A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up? 1.) Normal neurological findings are noted in a client with a cerebral aneurysm. 2.) A client with a spinal cord injury transfers himself from a bed to a wheelchair. 3.) A client who exhibits signs/symptoms of increased intracranial pressure after a craniotomy. 4.) A client who has sustained a stroke dresses herself.

3 Rationale: A client who exhibits signs/symptoms of increased intracranial pressure after a craniotomy, indicates a deterioration of the client's condition, requiring immediate follow-up. A case manager is a nurse who assumes responsibility for coordinating a client's care from the point of admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. The descriptions in the other options are expected outcomes.Test-Taking Strategy: Think about the role of the case manager and read each client description carefully. Focus on the subject, an unexpected client outcome. Note he strategic words "need for immediate follow-up". This indicates a negative event queryand will direct you to the description that is unexpected or unwanted. Signs/symptoms of increased intracranial pressure are an immediate concern, indicating deterioration in the client's condition.Review: expected and unexpected outcomes Level of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/EvaluationContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, Clinical JudgmentHESI Concepts: Professional Behaviors-Professionaism, Collaboration/Managing Care

A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he has gonorrhea." How should the nurse respond to the secretary? 1.) "Yes, he does, but be sure not to discuss this with anyone else." 2.) "Yes, that's why we've imposed contact precautions." 3.) "We can't discuss a client's medical condition." 4.) "Oh, really? I didn't see that!"

3 Rationale: A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's primary health care provider. Therefore the nurse must tell the unit secretary that the client's condition is not to be discussed. The statements "Yes, he does, but be sure not to discuss this with anyone else" and "Yes, that's why we've imposed contact precautions" both confirm the client's disease and are therefore inappropriate. Responding, "Oh, really? I didn't see that!" promotes further discussion of the client's condition and is inappropriate.Test-Taking Strategy: Focus on the subject, discussing a client's medical record with the unit secretary, and recall the issues surrounding confidentiality. This will help you eliminate the option that promotes further discussion of the client's condition. Next, eliminate the options that are comparable or alike in that they confirm the client's illness.Review: confidentialityLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Ethics, Health Care LawHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors-Professionalism

A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will he/she plan to care for first? 1.) A client who is able to perform activities of daily living independently 2.) A client in skeletal traction who has just received pain medication 3.) A client who is scheduled for surgery at 1 pm 4.) A client scheduled for physical therapy at 11 am

3 Rationale: For the client assignment presented, the RN would plan to care for the client who is scheduled for surgery at 1 pm first. Several items need to be addressed before surgery, including client preparation (physical and emotional) and primary health care provider prescriptions, all of which will take time. Also, many times the operating room will make late changes in the schedule, depending on room and primary health care provider availability, and will request an earlier surgical time. Therefore it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to a client. The needs of the client who is independent and the client scheduled for physical therapy later in the morning are not high priorities.Test-Taking Strategy: Focus on the subject, the client for whom the RN will care first. Note the strategic word "first". This indicates the most important client to care for at this time. Noting that an assigned client is scheduled for surgery and recalling the many needs of a client about to undergo surgery will direct you to the correct option.Review: prioritizingLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Care CoordinationHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Quality Improvement-Health Care Quality

The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? 1.) Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery 2.) Ask the client whether she would like to remove the wedding band or wear it to surgery 3.) Explain to the client why the wedding band must be removed 4.) Tape the wedding band in place

3 Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client's valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore, the appropriate nursing action is to ask the client to remove the wedding band and explain why.Test-Taking Strategy: Focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option.Review: preoperative careLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Perioperative Care Giddens Concepts: Cellular Regulation, Fluid and Electrolyte BalanceHESI Concepts: Cellular Regulation, Fluids and Electrolytes

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, what does the nurse tell the client? 1.) Anyone over the age of 18 years may sign a consent form for her treatment 2.) A consent form is not needed if the problem is a sexually transmitted infection 3.) She will need to sign an informed consent form 4.) Her mother or father will need to be contacted for permission to treat her

3 Rationale: Informed consent is a person's agreement to allow something, such as a treatment, to be performed. A consent form is needed if the problem is a sexually transmitted infection. If the client is a minor, he or she may sign the informed consent in the following situations: if the client is an emancipated minor; if the client is seeking birth control services or is pregnant; if the client is seeking treatment for a sexually transmitted infection, drug or substance abuse, or psychiatric services; or if a court order or other legal authorization has been obtained.Test-Taking Strategy: Focus on the subject, a minor client seeking medical treatment for a sexually transmitted infection, Eliminate the options that are comparable or alikein that they indicate that the consent form must be signed by another individual. To select from the remaining options, recall that a consent form is required for treatment.Review: informed consentLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Communication, Health Care LawHESI Concepts: Communication, Teaching and Learning-Client Education

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? 1.) Pulse 2.) Temperature 3.) Respiratory status 4.) Urine output

3 Rationale: Morphine sulfate depresses respiration, so the nurse must monitor the client's respiratory status closely. Although the incorrect options may be components of the assessment, checking respiratory status is the priority nursing action.Test-Taking Strategy: Focus on the subject, assessment of a client receiving an IV infusion of Morphine sulfate. Use the process of elimination, noting the strategic word"first." This indicates the priority action the nurse should take. Remember the ABCs — airway, breathing, and circulation — to guide you to the correct option.Review: continuous IV infusion of morphine sulfateLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, SafetyHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation? 1.) The client is voiding large amounts 2.) The client's wound is healing well 3.) The client's intake was 360 mL 4.) The client seems anxious

3 Rationale: Quality documentation and reporting have five important characteristics: factual, accurate, complete, current, and organized. Using an accurate measurement of intake is correct. The use of the word "seems" indicates that the nurse did not know the facts. Using the word "well" is also incorrect, because it does not provide an accurate observation. Likewise, using the word "large" does not provide an accurate measurement.Test-Taking Strategy: Focus on the subject, proper guidelines for documentation. Recall the characteristics of quality documentation and reporting. Also note that the correct option is the only one that is specific.Review: documentationLevel of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/EvaluationContent Area: Communication and DocumentationGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Professional Behaviors-Professionaism, Quality Improvement-Health Care Quality

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? 1.) Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift 2.) Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed 3.) Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay 4.) Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise

3 Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or "looking back," audit, the medical record is inspected after the client's discharge for documentation of compliance with standards. In a concurrent, or "at the same time," audit, the nursing staff's compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client's stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client's medical record from the medical record room for the purpose of reviewing documentation made during the client's hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits.Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the strategic word "retrospective" in the question and the description in the correct option.Review: quality improvement and retrospective and concurrent audits Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Leadership/Management Giddens Concepts: Health Care Quality, LeadershipHESI Concepts: Collaboration/Managing Care—Leadership, Quality Improvement/Health Care Quality

A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to deal with the conflict? 1.) Ignore the resistance 2.) Tell the LPN that his/her noncompliance will be documented in his personnel record 3.) Confront the LPN and encouraging him/her to express his/her feelings regarding the change 4.) Tell the LPN that a registered nurse will perform all of the computer documentation if he/she will document all intake and output and vital signs

3 Rationale: The best approach is to speak directly to the LPN and encourage the LPN to express feelings about the change. Confrontation is an important strategy in dealing with resistance. Face-to-face meetings to confront the issue at hand allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Ignoring the resistance does not address the problem. Providing a temporary solution to the resistance by having the registered nurse do all of the computer work and having the LPN perform only specific documentation will not specifically address the concern. Telling the LPN that the noncompliance will be documented in his personnel record may produce additional resistance.Test-Taking Strategy: Focus on the subject, the best approach to dealing with a conflict. and eliminate the options that are comparable or alike in that they represent direct avoidance of the conflict. Note the strategic words "best approach". This indicates the most effective way to deal with the conflict.Review: dealing with conflictLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, CommunicationHESI Concepts: Professional Behaviors-Professionalism, Communication

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she/he understands how a care map is used. Which response indicates understanding? 1.) "The care map is developed by a nurse and identifies nursing diagnoses." 2.) "The care map is a plan that is used only by the nurse to provide client care." 3.) "The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge." 4.) "The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis."

3 Rationale: The care map is a type of critical pathway that incorporates expected day-to-day client outcomes and those anticipated at discharge or at the end of a treatment phase. It outlines clinical assessments, treatments and procedures, dietary interventions, activity and exercise therapies, client education, and discharge planning. It may identify nursing diagnoses but is developed by members of all disciplines that normally care for the particular client type and is used by all members of the interdisciplinary team. Continuity of care can be achieved with the use of a care map.Test-Taking Strategy: Eliminate the options that are comparable or alike in that they refer to the care map as a nursing tool only. Also note that the correct option is the umbrella option.Review: care mapLevel of Cognitive Ability: EvaluationClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/EvaluationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Health PolicyHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Health Policy/Systems

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? 1.) Call the client's primary health care provider 2.) Report the nurse who changed the IV solution 3.) Ask the nurse whether he/she intends to report the error 4.) Document the error in the client's chart

3 Rationale: The first thing the nurse who observed the error should do is ask the nurse whether he/she intends to report the error. As means of helping ensure client safety, all errors must be reported to the physician, but this is not the initial action. The client also needs to be assessed immediately. An incident report should be completed by the nurse who discovered the error (the nurse who changed the intravenous solution). The appropriate documentation also must be made in the client's record by the nurse who discovered the error. If the nurse who discovered the error indicates that the error will not be reported, it may be necessary for the other nurse to contact the supervisor.Test-Taking Strategy: Focus on the subject, nurse who observed a correction of IV therapy. Use the process of elimination, noting the strategic word "first." This indicates the next action taken by the nurse who observed the error. Eliminate the options that are comparable or alike in that they involve reporting the error. To select from the remaining options, think about the principles of dealing with conflict. This will direct you to the direct option.Review: error in careLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Professional Behaviors-Professionalism, Communication

A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse's behavior has caused problems with client care during lunch hours. What is the most appropriate way for the nurse manager to deal with this situation? 1.) Ignoring the situation 2.) Documenting the problem in the nurse's personnel file 3.) Confronting the nurse to discuss the behavior and initiate problem-solving measures 4.) Asking other staff members to cover for the nurse

3 Rationale: The nurse manager must confront the nurse, discuss the behavior, and initiate problem-solving measures to ensure that the behavior does not continue. Taking extended lunch breaks is an unacceptable behavior, mainly because the behavior affects client care. Ignoring the situation, asking other staff members to cover for the nurse, and documenting the problem in the nurse's personnel file are all inappropriate because none of these actions will resolve the problem.Test-Taking Strategy: Focus on the subject, dealing with staff member taking extended meal breaks. Note the stratgegic words "most appropriate". This indicates the best way to deal with the situation. Remember your knowledge of the principles of dealing with conflict and unacceptable behavior and that it is most appropriate to confront and address a problem when it occurs. Also note that the incorrect options are comparable or alike in that they avoid the problem.Review: conflictLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, CommunicationHESI Concepts: Communication, Clinical Decision Making-Clinical Judgment-Critical Thinking

A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next? 1.) Rechecking the pulse oximetry reading 2.) Calling the primary health care provider 3.) Oxygenating the client with 100% oxygen 4.) Calling the respiratory therapist

3 Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen. Although the nurse would monitor the client's pulse oximetry, an improvement would not be expected until the client is reoxygenated. It is not necessary to contact the primary health care provider or the respiratory therapist at this time.Test-Taking Strategy: Focus on the subject, client with 89% oxygen. Use the ABCs — airway, breathing, and circulation — to answer the question. This will direct you to the correct option.Review: suctioning trach tubeLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Nursing Interventions

A nurse is assisting a primary health care provider in assessing a hospitalized client. During the assessment, the primary health care provider is paged to report to the recovery room. The primary health care provider leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? 1.) Telling the primary health care provider that the prescription will not be implemented until it is documented in the client's record 2.) Calling the nursing supervisor to obtain permission to accept the verbal prescription 3.) Asking the primary health care provider to write the prescription in the client's record before leaving the nursing unit 4.) Changing the solution and rate of the IV fluid per the physician's verbal prescription

3 Rationale: The primary health care provider should write all prescriptions. Verbal prescriptions are not recommended, because they increase the risk for error. If a verbal prescription is necessary, such as during an emergency, it should be written and signed by the primary health care provider as soon as possible, usually within 24 hours. The nurse must follow agency policies and procedures regarding verbal prescriptions. The appropriate nursing action would be to ask the primary health care provider to write the prescription in the client's record before leaving the nursing unit. Changing the solution in keeping with the verbal prescription and contacting the supervisor to obtain permission to accept the verbal prescription each imply that the nurse accepts the verbal prescription. Telling the primary health care provider that the prescription will not be implemented until it is documented in the client's record delays necessary treatment. Test-Taking Strategy: Focus on the subject,verbal prescriptions given by a primary health caré provider. Note the strategic word "appropriate." Eliminate the options that are comparable or alike in that they imply acceptance of the verbal prescription by the nurse. To select from the remaining options, recall the guidelines and principles for implementing primary health care provider prescriptions. This will direct you to the correct option.Review: verbal prescriptionsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Health Care Policy, SafetyHESI Concepts: Health Policy/Systems—Health Care Policy, Safety

The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant? 1.) A client who is getting up to ambulate for the first time after surgery 2.) A client who has just undergone cardiac catheterization 3.) An unconscious client who requires oral care 4.) A client scheduled for a liver biopsy

3 Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. Oral care may be delegated to a nursing assistant. The nurse would provide instructions to the nursing assistant regarding the task, how to adapt the procedure for the client at risk for aspiration, and the signs/symptoms of complications that must be reported immediately (e.g., bleeding gums, excessive coughing). A client who has just undergone cardiac catheterization requires monitoring for complications, and a client scheduled for liver biopsy requires preparation for the test and client teaching. A client who is getting up to ambulate for the first time after surgery is at risk for orthostatic hypotension and should be assisted by a licensed nurse.Test-Taking Strategy: Focus on the subject, client the nurse should assign to a nursing assistant. Note that the question asks for the assignment to be delegated to the nursing assistant. When asked questions related to delegation, think about the role description of the employee and the needs of the client. For the nursing assistant, select the client who has needs that do not require a high skill level, meaning that assessment, teaching, and monitoring are not appropriate. Note that two of the incorrect options are comparable or alike in that they identify clients who have undergone invasive procedures.Review: delegation Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing Care

A nurse has delegated several nursing tasks to staff members. What is the nurse's primary responsibility after delegation of these tasks? 1.) Assigning any tasks that were not completed to the next nursing shift 2.) Documenting completion of each task 3.) Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. 4.) Allowing each staff member to make judgments when performing the tasks

3 Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore it is the nurse's primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Not all staff members have the education, knowledge, and ability to make judgments about the tasks being performed. The nurse would document that the task was completed, but this would not be done until follow-up had been conducted and outcomes identified. It is not appropriate to assign the tasks that have not been completed to the next nursing shift; this action does not ensure that client needs will be met and also increases the workload for the next shift.Test-Taking Strategy: Focus on the subject, nurse's primary responsiblity after delegating tasks. Use the process of elimination, noting the strategic words "primary responsibility." Recalling that the ultimate responsibility for a task lies with the person who delegated it will direct you to the correct option.Review: delegationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Care Coordination. Clinical JudgmentHESI Concepts: Professional Behaviors-Professionalism, Communication

A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? 1.) A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures 2.) A client on bedrest who needs assistance with feeding 3.) A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments 4.) A client who must be turned and repositioned every 2 hours

3 Rationale: When a nurse delegates aspects of a client's care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. A client receiving oxygen who requires pulse oximetry monitoring and respiratory treatments should be assigned to the LPN, because this staff member can perform these tasks and is competent to note changes in the client's condition. Feeding a client, turning and repositioning a client, and assisting with hygiene measures, all noninvasive interventions, may be assigned to a nursing assistant.Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment of tasks to an LPN. Think about the activities that the LPN is able to perform. Next, eliminate the options that are comparable or alike in that they are noninvasive procedures.Review: delegation Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Quality Improvement-Health Care Quality

A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply. 1.) A client who is confused and requires assistance with a shower 2.) A client who must be accompanied to physical therapy twice during the shift 3.) A client with a colostomy who requires reinforcement regarding the procedure for irrigation 4.) A client requiring a bed bath and frequent ambulation with a cane 5.) A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

3,5 Rationale: When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned the tasks of caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to reinforce teaching regarding the colostomy irrigation (the RN is responsible for the initial teaching) and administering regular insulin in accordance with a sliding scale.Test-Taking Strategy: Focus on the subject, the client assignment for the LPN. to eliminate the clients whose needs are noninvasive, because a nursing assistant may perform these tasks. This will help you identify the clients who may be assigned to the LPN.Review: delegationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. What are the reasons for the nurse to review the chart? Select all that apply. 1.) Be aware of the geographical area that the organization serves 2.) Be familiar with the beliefs and values of the organization 3.) Be familiar with the organization's line of authority 4.) Understand the organization's reason for existence 5.) Understand the way an organization depicts how activities are arranged 6.) Be knowledgeable of how communication channels are established

3,5,6 Rationale: An organizational chart depicts and communicates how activities are arranged, how authority relationships are defined, and how communication channels are established. Understanding the organization's reason for existence, geographical area, and the beliefs and values of the organization are all components of the organization's mission statement.Test-Taking Strategy: Focus on the subject, purpose for reviewing an organizational chart. Remember your knowledge of the components of an organizational chart to answer this question.Review: organizational chartLevel of Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Leadership, CaregivingHESI Concepts: Professional Behaviors-Professionalism, Health Policy/Systems

A nurse working the 7 am-to-3 pm shift is reviewing the records of him/her assigned clients. Which client should the nurse assess first? 1.) A client scheduled for contrast computed tomography (CT) at noon 2.) A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am 3.) A client scheduled for a nuclear scanning procedure at 10 am 4.) A client scheduled for hemodialysis at 10 am

4 Rationale: A client scheduled for hemodialysis has needs that must be met before the procedure. The nurse must ensure that the client is physically and emotionally ready for the treatment, which may take as long as 5 hours. Before the treatment, the nurse must assess the client, including looking for fluid overload by checking the client's weight and lung sounds. The nurse must also assess the client's predialysis vital signs and the results of laboratory tests for comparison in the postdialysis period. Although the clients described in the other options have needs, they are not immediate. A client scheduled for a nuclear scanning procedure at 10 am may require reinforcement of information about the procedure and will need to increase fluid intake before the procedure. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am may require pain medication, but the medication should be administered approximately 30 minutes before the hydrotherapy. A client scheduled for contrast CT at noon may require reinforcement of information about the procedure and may need to drink a special contrast preparation just before the procedure.Test-Taking Strategy: Focus on the subject, what client to assess first. Note the strategic word "first". This indicates the client who is most important to assess. Use Maslow's Hierarchy of Needs theory and think about the needs of each client and what pretesting or preprocedure preparation involves. Although all of the clients have physiological needs, the client scheduled for hemodialysis has the priority need, that being the risk of fluid overload.Review: Assessment prioritiesLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care En vironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Making-Clinical Judgment-Critical Thinking

The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? 1.) Telling the client that the medal and chain will be kept at the nurses' station for safekeeping while the client is undergoing the x-ray 2.) Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department 3.) Asking the client to remove the medal until the x-ray has been completed 4.) Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms

4 Rationale: A client undergoing a chest x-ray must remove all metal objects to help prevent artifacts on the x-ray. If the client expresses concern about removing the medal, the nurse should help the client pin the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. The nurse should also alert staff in the radiology department that this has been done. If the client is expressing concern about removing the medal, asking the client to remove it or leave it with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the likelihood that the medal and chain will be lost.Test-Taking Strategy: Focus on the subject, client wearing a religious medal around the neck and scheduled for a chest x-ray. Note that the client is expressing concern about removing the religious medal. Also note the strategic words "most appropriate". This indicates the best action in this situation. Eliminate the options that are comparable or alike in that they indicate that the client should remove the medal. Also note that the correct option is the only option that addresses the client's concern.Review: clients' valuables Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Safety Giddens Concepts: Culture, SafetyHESI Concepts: Safety, Spiritual/Cultural

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, what would be the firstactivity that the nurse would suggest to the task force? 1.) Distributing fliers that identify the causes of school violence to families in the community 2.) Teaching schoolchildren about the dangers of school violence 3.) Looking at what other communities are doing about school violence 4.) Conducting a community survey to assess community perceptions regarding school violence

4 Rationale: An assessment activity is always the first step in the nursing process. Conducting a community survey on school violence addresses assessment of community perceptions. Teaching schoolchildren about the dangers of violence and distributing fliers that identify the cause of school violence are implementation measures. Looking at what other communities are doing is part of the analysis of a variety of assessment data but is not specific to the subject of the question.Test-Taking Strategy: Focus on the subject, interventions to help prevent violence. Note the strategic word "first". This indicates the initial activity taken by the members of the task force. Use the steps of the nursing process to answer the question. Eliminate the options that are implementation actions. To select from the remaining options, note the strategic word "assess" in the correct option.Review: assessmentLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Leadership/ManagementGiddens Concepts: Collaboration Health Care QualityHESI Concepts: Professional Behaviors-Professionalism, Collaboration/Managing Care

A client asks the nurse about the procedure for becoming an organ donor. What should the nurse tell the client? 1.) That this decision must be made by the next of kin at the time of the client's death 2.) To speak with the chaplain about the psychosocial aspects of becoming a donor 3.) To let the primary health care provider know about the request so that it may be documented in the client's record 4.) That anatomical gifts should be made in writing and signed by the client

4 Rationale: An individual who is at least 18 years old may make an anatomical gift of all or part of the human body. The gift must be made in writing and signed by the donor. If the client cannot sign, the document must be signed by another individual and two witnesses. The primary health care provider is informed of the client's wishes and the client may wish to speak to a chaplain, but the specific procedure requires a written document signed by the client. The family of a deceased client may be asked about organ donation, but this is not the procedure when a living person wishes to become a donor.Test-Taking Strategy: Focus on the subject, a client requesting information about organ donation. Eliminate the option using the closed-ended word "must." To select from the remaining options, remember that an anatomical gift must be made in writing and signed by the client.Review: organ donationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Client Education, Health Care LawHESI Concepts: Health Policy/Systems—Health Care Law, Teaching and Learning/Client Education

Which of the following situations is an example of the use of evidence-based practice in the delivery of client care? 1.) Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab 2.) Encouraging a client who has had a stroke to consume thin liquids and foods 3.) Immediately picking up a dislodged radiation implant with gloved hands and placing it in a lead container 4.) Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

4 Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into the sterile basin reflects evidence-based practice because this action cleans the lip of the bottle, thus preventing the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Encouraging a client with a stroke to consume thin liquids and foods could cause harm because of the risk for choking; instead, such a client should receive thickened liquids. A dislodged radiation implant should be picked up with the use of long-handled forceps, not gloved hands, to be placed in a lead container to minimize radiation exposure. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab recontaminates the stick site.Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note that the correct option prevents the entrance of harmful bacteria into the wound.Review: evidence-based practiceLevel of Cognitive Ability: UnderstandingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Evidence, Health Care QualityHESI Concepts: Clinical Decision Malong-Clinical Judgment-Critical Thinking, Evidence Based Practice-Evidence

The nurse reviewing a client's record sees that the following medications are prescribed. Which medication should the nurse plan to administer first?Client Medications1. Atorvastatin 10 mg orally 2. Zolpidem 5 mg orally daily3. Ferrous sulfate 1 tablet orally 4. Levothyroxine 137 mg orally 1.) 2 2.) 1 3.) 3 4.) 4

4 Rationale: For adequate absorption, levothyroxine must be administered with water on an empty stomach as soon as the client awakens and at least 1 hour apart from other fluids (e.g., coffee or tea), food, and other medications. Therefore this medication should be administered first. Atorvastatin, an HMG-CoA reductase inhibitor used to lower cholesterol, is administered at bedtime because cholesterol synthesis is increased during the night. Zolpidem, a benzodiazepine-like medication used to enhance sleep, is administered at bedtime. Ferrous sulfate is an iron supplement that is administered with water between meals.Test-Taking Strategy: Note the strategic word "first." Think about the classification of each medication to determine its action. This will help you answer correctly. Also note that atorvastatin and zolpidem are comparable or alike in that they are administered at bedtime. Next, recalling the action of levothyroxine will direct you to this option.Review: LevothyroxineLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Health PromotionHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Nursing Interventions

A man who is visiting his wife in a long-term care facility for people with Alzheimer's disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital primary health care provider that the client has no other family members and that his wife is mentally incompetent. The client's primary health care provider writes a DNR order. What knowledge by the registered nurse indicates a need for further education? 1.) That the DNR order will be reviewed according to hospital policy. 2.) That the client's other medical conditions must be treated. 3.) That the DNR order has been ethically and legally implemented. 4.) That everything possible must be done if the client stops breathing.

4 Rationale: Further education is needed if the nurse does everything if the client stops breating. In a situation in which a client has no family members who can provide permission for treatment, the primary health care provider may write a DNR order if he or she is reasonably and medically certain that resuscitation would be futile. This order has been ethically and legally put in place and should be reviewed according to hospital policy. However, the client's other medical conditions must be treated. Test-Taking Strategy: Focus on the subject, need for further education. The written DNR order is ethical and legal and the nurse should not do everything if the client stops beating. The other options are true.Review: DNR Level of Cognitive Ability: AnalyzingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Ethical/LegalGiddens Concepts: Clinical Judgment, EthicsHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Professional Behaviors-Professionalism

A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant? 1.) Ambulating a client with Parkinson's disease 2.) Providing hygiene to a client with dementia 3.) Assisting a client with an above-the-knee amputation in showering 4.) Assisting a client with dysphagia in eating

4 Rationale: In this case, the least appropriate assignment for a nursing assistant would be assisting a client with dysphagia with eating because of the risk of complications such as choking and aspiration. The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. The remaining three situations include no data to indicate that these tasks carry any unforeseen risk.Test-Taking Strategy: Note the strategic words "least appropriate." Use the ABCs — airway, breathing, and circulation — and recall the principles of delegation and supervision of tasks in answering the question. Remember, delegation of work must be consistent with the individual's level of expertise and licensure or lack of licensure.Review: assignments and delegationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Health Care QualityHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Collaboration/Managing Care

A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? 1.) Autonomy 2.) Fidelity 3.) Justice 4.) Nonmaleficence

4 Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person's independence and represents an agreement to respect another's right to determine his or her course of action.Test-Taking Strategy: Focus on the subject - the ethical principle being utilized. Recall the definition of each item in the options. Note the relationship of the strategic words"least possible harm" in the question and the definition of nonmaleficence.Review: NonmaleficienceLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Celluar Regulation, EthicsHESI Concepts: Advocacy/Ethical/Legal Issues, Cellular Regulation

A primary health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client with what types of power? 1.) Coercive power 2.) Reward power 3.) Information power 4.) Expert power 5.) Position power 6.) Referent power

4 Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that are needed by others. Nurses who teach clients use expert and information power by virtue of the information they share with clients. They also exercise position power because they are registered nurses and therefore are accorded a certain status by society. Reward power is based on the ability to be able to grant rewards and favors. Coercive power is based on fear and the ability to punish. Referent power results from followers' desire to identify with a powerful person.Test-Taking Strategy: Focus on the subject, types of power exhibited by the colostomy nurse. Note the data in the question and that a consultation is being sought from another healthcare team member in the care of a client. This will direct you to the correct options.Review: types of power and consultations.Level of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, Client EducationHESI Concepts: Professional Behaviors-Professionalism, Teaching and Learning-Client Education

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. What is the best action by the nurse conducting the program? 1.) Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization 2.) Allow the television crew to videotape the program 3.) Ask the television crew to interview the individuals attending the program individually 4.) Explain to the television crew that videotaping is not allowed

4 Rationale: Privacy is a client's right to be free from unwanted intrusion into his or her private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for an action such as photographing or videotaping. Therefore the nurse must explain to the television crew that videotaping is not allowed. The other options are incorrect and constitute invasions of client privacy.Test-Taking Strategy: Focus on the subject, client privacy. Note the strategic word bestbecause ths refers to the option that is the most apporpriate response. Eliminate the options that are comparable or alike in that they represent invasions of client privacy.Review: client privacyClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Leadership, EthicsHESI Concepts: Advocacy/Ethical/Legal Issues-Ethics, Clinical Decision Making-Clinical Judgement-Critical Thinking

A nurse manager discusses staff empowerment with the nursing team. What does the nurse manager tell the staff what empowerment means? 1.) Allows the staff to make every decision regarding employee scheduling 2.) Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes 3.) Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery 4.) Fosters the growth of others so that they are less dependent on the leader

4 Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. Staff do not have the power to reprimand and punish or make decisions regarding scheduling or the nursing unit.Test-Taking Strategy: Focus on the subject, what empowerment means. Think about the definition of the term empowerment and note the relationship of this definition and its relationship to the information in the correct option.Review: empowermentLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, LeadershipHESI Concepts: Professional Behaviors-Professionalism, Communication

The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? 1.) Threatening to give a client a medication against his or her will 2.) Observing the provision of care to the client without the client's permission 3.) Performing a procedure without consent 4.) Telling the client that he or she may not leave the hospital

4 Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual's private affairs. Observing the provision of care to a client without the client's permission is an example of invasion of privacy.Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option.Review: false imprisonmentLevel of Cognitive Ability: EvaluatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Ethical/Legal Giddens Concepts: Health Care Law, Leadership HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care Law

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriateresponse by the nurse? 1.) Telling the client that she needed to ask these questions before signing the informed consent for surgery 2.) Informing the client that she has the right to cancel the surgical procedure if she wishes 3.) Telling the client that it is her surgeon's responsibility to explain the procedure 4.) Contacting the surgeon and requesting that he/she visit the client to answer her questions

4 Rationale: The most appropriate response by the nurse is to ask the surgeon and to visit the client in order to answer questions the client has about the surgery. Informed consent is the authorization by a client or a client's legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client's part, the nurse has the obligation to contact the surgeon. Telling the client that she needed to ask questions before signing the consent for surgery is incorrect. Although the client should be thoroughly informed before signing consent, the client has the right to ask questions thereafter. It is the surgeon's responsibility to explain the procedure, and, if the client wishes, she has the right to cancel the surgical procedure. Although these are correct statements, they are not the most appropriate and do not address the client's concerns. Additionally, they do not address the legal ramifications associated with informed consent.Test-Taking Strategy: Focus on the subject, nurse's response to client who does not have an adquate understanding of a mastectomy. Note the strategic words "most appropriate". This indicates the best response that the nurse can make. Recall that the primary health care provider is primarily responsible for explaining the surgical procedure to the client will direct you to the correct option.Review: informed consentLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Ethical/LegalGiddens Concepts: Clinical Judgment, CommunicationHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Advocacy/Ethical/Legal Issues-Ethics

A nurse manager arrives at work and is immediately faced with several activities that require attention. Which activity will the nurse manager attend to first? 1.) A phone message from employee health services 2.) A phone message from a client's wife 3.) Stocking the medication closet 4.) Client assignments for the day

4 Rationale: The nurse manager must attend to client assignments first, because client care is the priority. Also, the nursing staff need their assignments so that they may begin client assessments and start delivering client care. The nurse manager should next check the medication supply to ensure that needed medications are available. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next return the phone calls.Test-Taking Strategy: Focus on the subject, activity the nurse manager attends to first. Note the strategic word "first" and and prioritization skills. Remember that the client is the priority. Eliminate the options that are not directly related to immediate client needs. This will direct you to the correct option.Review: time managementLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, LeadershipHESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Malong-Clinical Judgment-Critical Thinking

The nurse calls a primary health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The primary health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes? 1.) The primary health care provider made an error in the written prescription for morphine sulfate. 2.) An incorrect dosage of morphine sulfate was prescribed and the primary health care provider was notified. 3.) The primary health care provider was called to correct an error in the dosage of morphine sulfate. 4.) The primary health care provider was called to clarify the prescription for morphine sulfate.

4 Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made an error or performed an incorrect action or procedure. If a primary health care provider's prescription must be questioned, the nurse should record that clarification regarding the prescription was sought.Test-Taking Strategy: Focus on the subject, primary health care provider changing his/her prescription. Eliminate the options that are comparable or alike in that they indicate that the primary health care provider made an error in writing a prescription. These options contain the words "error" or "incorrect."Review: documentationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal Giddens Concepts: Health Care Policy, PainHESI Concepts: Health Policy/Systems—Health Care Policy, Pain

A client receives cefazolin sodium by way of the intravenous route. During the infusion, the client begins exhibiting signs/symptoms of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. What does the nurse most accurately document? 1.) The primary health care provider was notified because a rash developed while the client was receiving cefazolin sodium. 2.) The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back. 3.) The client had an allergy to cefazolin sodium. 4.) During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The primary health care provider was notified.

4 Rationale: The nurse should document relevant information in an accurate, complete, and objective form. Noting the client had an allergy to cefazolin sodium does not identify objective data. Assuming that the client is allergic to cefazolin sodium because of warm and flushed skin makes an interpretation about the occurrence. Documenting that the primary health care provider was notified because the client developed a rash while receiving the medication identifies accurate data, but is incomplete.Test-Taking Strategy: Focus on the subject, documenting action taken by the nurse on a client with a allergic reaction. Note the strategic words "most accurately". This indicates the most complete documentation. Use the process of elimination, recalling that documentation should include relevant information in an accurate, complete, and objective form. This will direct you to the correct option. Also note the relationship of the data in the question and in the correct option.Review: documentationLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Leadership/ManagementGiddens Concepts: Clinical Judgment, CaregivingHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Quality Improvement-Health Care Quality

The nurse notes that a primary health care provider has documented the following prescription in a client's record: Furosemide 40 mg stat once. What action should the nurse take? 1.) Administer the medication 2.) Plan to have the nurse on the next shift administer the medication 3.) Draw up the medication in a syringe 4.) Contact the primary health care provider

4 Rationale: The nurse would contact the primary health care provider and ask about the route of the medication. The medication prescription must include the medication name, dose, route of administration, time, and frequency of the administration. The nurse would not prepare the medication or administer it without first checking with the physician. A stat prescription must be administered immediately. Therefore, it is inappropriate to plan to have the nurse on the next shift administer the medication.Test-Taking Strategy: Focus on the subject, action by nurse to follow-up on incomplete prescription. Read the prescription and think about the procedure for fulfilling a prescription. This will reveal that the route of administration is not specified.Review: medication prescriptionsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Medication AdministrationGiddens Concepts: Clinical Judgment, CommunicationHESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Communication

A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. What should the nurse do to determine the necessary actions in regard to this client's injury? 1.) Call the nurse in charge of the day shift 2.) Ask the police officers who brought the client to the ED 3.) Ask a licensed practical nurse 4.) Check the unit policy for the protocol for the care of clients who have been sexually assaulted

4 Rationale: The policy or protocol for a client who has been raped will describe the physical, psychosocial, and legal responsibilities of the nurse. A policy or procedure is a designated plan or course of action to be taken in a specific situation. Written copies of all policies are usually placed in a policy manual that is available in each department or may be available online. Specific unit policies are sometimes referred to as protocols. Calling the nurse in charge during the day shift or asking an LPN or the police officers who brought the client into the ED is inappropriate. If the nurse needs additional information after reviewing the policy or protocol, it would be most appropriate to contact the agency nursing supervisor of the night shift.Test-Taking Strategy: Focus on the subject, care of a client who has been sexually assaulted. Use the process of elimination, recalling the legal implications related to providing care. Note that the incorrect options are comparable or alike in that they suggest obtaining information from other individuals.Review: organizational policies, procedures, or protocolsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, LeadershipHESI Concepts: Professional Behaviors-Professionalism, Advocacy/Ethical/Legal Issues-Ethics

The nurse and an assistive personnel (AP) enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first? 1.) Ask the nursing assistant to assist in getting the client back to bed 2.) Contact the unit secretary on the intercom and ask that the client's primary health care provider be called 3.) Ask the nursing assistant to complete an incident report 4.) Check the client's level of consciousness and vital signs

4 Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the AP to assist in getting the client into bed. The nurse should then contact the primary health care provider and file an incident report.Test-Taking Strategy: Note the strategic word "first." Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall.Review: Client who fallsLevel of Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Delegating/Prioritizing Giddens Concepts: Mobility, SafetyHESI Concepts: Mobility, Safety

A nurse is planning care for her assigned clients. What does the nurse know about the purpose of the hospital's standards of care? Select all that apply. 1.) Identify new care methods on the basis of current medical research 2.) Evaluate current methods of treatment 3.) Provide direction for care on the basis of the client's diagnosis 4.) Provide competent care on the basis of current practice 5.) Identify methods of treatment 6.) Provide direction for the practice of nursing

4,6 Rationale: The purpose of standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, across the country. Standards of care include the provision of competent care on the basis of current practice. Methods of treatment are individualized to the care of a specific client. Providing direction of care on the basis of the client's diagnosis is a matter of medical interventions. New care methods are a matter of research. Evaluate current methods of treatment are included in the standards of care purpose. Test-Taking Strategy: Focus on the subject, standards of care. Note the relationship of the subject and the information in the correct option. The correct option is also the umbrella option.Review: standards of careLevel of Cognitive Ability: Applying Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/PlanningContent Area: Leadership/ManagementGiddens Concepts: Professional Identity, EvidenceHESI Concepts: Professional Behaviors-Professionalism, Evidence Based Practice-Evidence