MS3-PassPoint: Practice Test #1

The family of a hospitalized client demonstrates understanding of the teaching about legal documents related to end-of-life care such as "advance directive" and "power of attorney" when they make which statements? Select all that apply.

Correct response: "Advance directives give instructions about future medical care and treatment." "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself." Explanation: Advance directives are written statements of person's wishes related to health care if they are unable to decide for themselves. Power of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter. These documents relate to current or future health care and not past medical history. Competent adults are responsible for their own health care decisions and their own right to accept or refuse treatment. Advance directives are used when the person cannot make the decision. Medical power-of-attorney is a term used to describe the person who makes health care decisions should someone be unable to make informed decisions for himself or herself. The focus is not primarily financial access.

The nurse is caring for a client on a ventilator in the intensive care unit (ICU). A person who claims to be the client's neighbor approaches the nurse and asks how many days the client will remain in the ICU. What is the best response by the nurse?

Correct response: "I am unable to share medical information without authorization by the client." Explanation: Privacy Acts state that all information in government records must remain private and confidential (such as client health records). It would be a violation of the client's privacy to share any medical information with a neighbor who has not been authorized. The nurse would not make predictions about the length of stay. Encouraging the neighbor to speak with the healthcare provider passes responsibility of explaining privacy laws to the healthcare provider and is inappropriate.

The nurse is performing a medication reconciliation, and the client requests a green coffee bean supplement to lose weight. What is the nurse's best response?

Correct response: "I will call your healthcare provider and tell them you are interested in adding the supplement to your medication regime." Explanation: The nurse needs to contact the healthcare provider (HCP) to complete the medication reconciliation process. The supplement should be added to the regimen only after the HCP has assessed potential contraindications and given approval. While it may be appropriate to inform clients that herbal supplements and alternative therapies do not always have scientific evidence to support their use, merely informing the client of this does not address the request. The nurse can determine how to obtain the green coffee bean supplement if the HCP approves of it.

A client with a history of painful, continuous muscle spasms is prescribed diazepam, 2 mg P.O. twice daily. The client states the medication is effective and requests to use it long term. Which response by the nurse is most appropriate?

Correct response: "Long-term use of this medication may result in addiction." Explanation: Diazepam is used for only short-term management of muscle spasms because it is potentially addictive. The nurse doesn't have the authority to tell the client to continue to take the drug, and the nurse should not speak for the healthcare provider. Bradycardia is not a known adverse outcome of diazepam.

The nurse educates a client with terminal cancer about advance directives, living wills, and healthcare power of attorney. When evaluating the teaching offered, the nurse interprets which client response as evidence of successful instruction?

Correct response: "These documents can guide my treatment in certain healthcare situations if I am not able." Explanation: Advance directives are signed, witnessed documents that provide specific instructions for treatment if a client can't give those instructions personally when required. Depending on the client's wishes, an advance directive may or may not include do-not-resuscitate orders. Advance directives allow the client, not the healthcare provider, to make decisions about treatment. The client's family may or may not have input depending on how the client stipulates the details in the advanced directive and living will.

A client on a surgical unit provided consent for a liver biopsy. The nurse is in the process of taking the client to the operating room when the client states, "I've changed my mind." Which response by the nurse is accurate?

Correct response: "You have the right to withdraw consent. Would you like to discuss this further?" Explanation: Clients have the right to withdraw consent at any time. Assuring the client that "everything will be all right" or suggesting the client is merely feeling anxious ignores the client's concern. Stating that there are risks for not going through with the procedure puts pressure on the client to agree to a procedure that the client may no longer feel comfortable with.

An experienced licensed practical/vocational nurse (LPN/VN) is working with the RN team leader to care for a client with respiratory problems. Which actions are appropriate for nurse to delegate to the LPN/VN? Select all that apply.

Correct response: -Check oxygen saturation with pulse oximetry. -Auscultate breath sounds. -Administer medications by metered-dose inhaler. Explanation: The seasoned LPN/VN is capable of gathering data and making observations, including auscultating breath sounds, measuring oxygen saturation by pulse oximetry, and administering medications by metered-dose inhaler. Admission assessments, initiating care plans, and evaluating a client's abilities require the extra education that the RN possesses.

A client was admitted to the emergency department (ED) following a workplace accident and has just experienced brainstem death. The nurse recognizes that the client is likely an appropriate donor for tissue and organs. What actions related to organ donation should the (ED) nurse perform?

Correct response: -Ensure that the family has a quiet, private place to discuss their decision around tissue donation. -Support and validate the decision that the client's family makes. Explanation: In most cases, it is not the role or responsibility of the nurse to initiate the first dialogue about organ or tissue donation following brainstem death. The nurse should answer any questions posed by the family, but the primary responsibilities include supporting and validating the family.

A client experienced an overdose of heroin. Providers administered naloxone along with CPR, but did not have success. How can the nurse best meet the needs of the family members? Select all that apply.

Correct response: -Find a private room to discuss the client's condition. -Be prepared to have ancillary staff available such as pastoral care and social work. -Allow for viewing of the body. Explanation: The nurse is responsible for caring for the client and client's family. The lead or charge nurse can be helpful in clarifying questions, but the nurse should be involved with the family. The nurse should allow the family to decide on postmortem care. The nurse should prepare the client but should not be involved in funeral arrangements.

The nurse is walking past the supply room on the hospital unit and sees smoke coming out from below the door. Opening the door, the nurse sees flames. Identify the correct sequence of the nurse's response. All options must be used.

Correct response: -Remove from the area anyone who is in immediate risk of harm. -Activate the fire alarm. -Contain the smoke and fire by closing windows, doors, and curtains. -Evacuate the area or extinguish the fire, as appropriate to the severity of the fire. Explanation: The response to an actual or suspected fire should follow these steps: R: Rescue the client by removing the client or the source of the fire. A: Activate the alarm. C: Confine the fire. E: Evacuate or extinguish, as appropriate to the fire.

The nurse is assigned to care for five clients. Which could be assigned by the nurse to the unlicensed assistive personnel (UAP)? Select all that apply.

Correct response: -a client post-operative appendectomy with BP 110/80 mm Hg, pulse 84 bpm -a client scheduled for cataract surgery with BP 134/78 mm Hg, pulse 70 bpm Explanation: The client who is post-operative from an appendectomy and the one awaiting cataract surgery are both stable and could therefore be assigned to the nursing assistant. The assistive personnel would need to report any changes in condition to the nurse. The others are not appropriate to reassign because there are immediate nursing interventions that need to be done.

The nurse is providing cost-effective, evidence-based care health education to a client. Which choices are examples of cost-effective, evidence-based care? Select all that apply.

Correct response: -education on healthy dietary choices -education on beginning an exercise regime Explanation: Cost-effective, evidence-based care includes education on healthy lifestyle choices. Education on extended health insurance plans and medical expenses can be provided but is not considered cost-effective care. Education on healthcare legislation is not the priority.

A client on the palliative unit discusses treatment with the nurse. The client wants to refuse further chemotherapy and request pain management strategies only. What is the appropriate action by the nurse in relation to the client's requests?

Correct response: Acknowledge the client's right to make the choices regarding treatment. Explanation: Client choice is always a priority. The other answers do not support the right of the client to make choices in the proposed medical interventions.

The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions?

Correct response: Assess the family's food preferences. Explanation: Before beginning dietary interventions, the nurse must assess the client's pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences.

A staff nurse would like to effect change to increase staffing levels on the nursing unit. What strategy should the nurse use to begin to create change on the unit?

Correct response: Assess the impact of staffing on client-care quality. Explanation: When preparing to propose an increase in staffing levels, the nurse should first assess the effect that increased staffing would have on the quality of client care. Assessing other factors such as institutional resources, standards of practice, and nursing recruitment will be important to implementing a plan for increased staffing levels, but none is as central to effecting change as quality of client care.

The experienced licensed practical/vocational nurse (LPN/VN) under the supervision of the registered nurse (RN) team leader is providing nursing care for an infant with respiratory syncytial virus. Which tasks are appropriate for the RN to delegate to the LPN/VN? Select all that apply.

Correct response: Auscultate breath sounds. Administer prescribed aerosolized medications. Check oxygen saturation using pulse oximetry. Explanation: LPN/VNs work collaboratively with colleagues in health care to assess, plan, and deliver quality nursing services. The experienced LPN/VN is capable of gathering data and observations including breath sounds and pulse oximetry. Administering medications, such as aerosolized medications, is within the scope of practice for the LPN/LVN. The actions that are within the scope of practice for the professional RN include independently completing the admission assessment, initiating the nursing care plan, and evaluating a parent's abilities, as these activities require additional education and skills.

A client with unilateral nerve deafness is admitted to the surgical unit. What is the most important intervention for the nurse to use when caring for this client?

Correct response: Be certain the client's position is considered prior to beginning a conversation. Explanation: When speaking to a client with a unilateral nerve deafness, the nurse takes into consideration the client's position to be sure that the conversation occurs on the side where the client has optimal hearing. Usually, a partially deaf person does not require extra time for conversations, nor the use of an interpreter. The usual postoperative care written instructions are reviewed and given to the client.

A nurse is preparing to conduct research and is searching the literature for evidence-based research information. Which source would the nurse most likely use to obtain appropriate information with the strongest level of evidence? Select all that apply.

Correct response: Cochrane Collaboration National Guideline Clearinghouse Johanna Briggs Institute Explanation: Information obtained from the Cochrane Collaboration and Johanna Briggs Institute are considered level I evidence which involve a systematic review of all relevant randomized controlled trials (RCTs). Information from the National Guideline Clearinghouse provides level I evidence, identifying clinical practice guidelines based on systematic reviews of RCTs. Information from MEDLINE and CINAHL provide reviews of descriptive or qualitative studies or articles of original quantitative studies, which are considered lower levels of evidence.

A multiparous client and her small-for-gestational-age neonate, who has been cared for in the intensive care nursery for the past 3 days, are to be discharged. Before their release, the mother tells the nurse, "I have been living in my car for the past 2 weeks." What should the nurse do next?

Correct response: Contact the hospital's social worker. Explanation: When a client is being released from the hospital with her neonate and the nurse learns that the client is homeless, the nurse should contact the hospital's or unit's social worker. Social workers have access to resources to assist the client to find temporary shelter in emergencies.The director of the birthing unit does not need to be notified. The director's responsibilities are primarily administrative.The client's HCP can be notified once the social worker has offered assistance to the client. The HCP may cancel the release of the neonate until temporary housing is located.Notifying any of the client's family members is inappropriate. The client may not have any immediate family members, or there may be some stress between the client and family members.

A client is having difficulty paying for complex home health care needs. Which action by the nurse promotes cost-effective care?

Correct response: Ensure client is utilizing all available options for assistance in paying for home health care. Explanation: As health care costs increase, the focus is shifting to outpatient care, preventative care, and health promotion. Clients are managing more complex medical conditions at home, leading to new challenges in health care. Paying for home care can be a challenge, and the nurse plays a key role in helping the client find and utilize all appropriate services for assistance in paying for home care. Recommending the client go to the emergency department for care or requesting admission to the hospital does not promote cost-effective care, and is not necessary for conditions that can be managed at home. Advising the client that there is nothing the nurse can do to help is not true, and does not promote cost-effective care, as the client will likely utilize higher-cost services for care, such as the emergency department, or will not get the care needed and may experience a worsening condition.

The nurse is caring for two children in the same room. The parents of one child ask the nurse about the condition of the other child. What is the most appropriate response by the nurse?

Correct response: Explain that giving information would violate confidentiality. Explanation: Evoke confidentiality and stress that you would also not share information about their child to anyone inquiring who was not directly responsible for the care of that particular child. None of the other answer options would be appropriate or professional.

A young woman with an ovarian cyst who recently emigrated from Laos has been admitted to the hospital. The client and her husband both speak Lao exclusively, which has complicated the ability of the care team to obtain informed consent for surgery. What action would the care team take to communicate with the client?

Correct response: Organize professional interpretation either in person or by telephone. Explanation: All clients have a right to unencumbered communication with a health provider; consequently, a professional interpreter is necessary. It is insufficient to communicate nonverbally, and it is usually inappropriate to have a family member translate. Having the client write her concerns does not resolve this problem.

A deceased client is a member of a culture where the family is expected to bathe the body after death. What should the nurse do to support the client and family at this time?

Correct response: Provide the needed supplies to the family. Explanation: In cultures where the family is expected to bathe the body, the family should be given the necessary supplies and left alone in the room with the body. The nurse should not interfere by participating with the family or directing the bathing procedure. The nurse should not bathe the body and expect the family to observe the process. Cultural practices are to be acknowledged and honored and facility personnel can permit the family to complete the task of bathing.

A physician writes an order for a nurse to administer an I.V. medication which, according to hospital policy, is not a nursing protocol. The nurse informs the physician that it is not a nursing protocol, and the physician states, "Give it, and I will cover you." What should the nurse do in this situation?

Correct response: Refuse to administer the medication. Explanation: The nurse should refuse to give the medication because hospital policy would not support giving it. Giving a medication and having someone else sign for it would be unethical and illegal. Asking another nurse would not be appropriate because the first nurse is aware that the drug should be given by a physician. The other choices are incorrect because the nurse would be working against hospital policy and outside of the scope of practice.

A nurse is discussing end of life care with a client's family in a skilled nursing facility. The client's advanced directive states the client wants no life support treatments. What are important nursing considerations to determine the efficacy of the advanced directive? Select all that apply.

Correct response: The client signed the form. The advanced directive has two signatures. The advanced directive has a durable power of attorney. Explanation: The nurse determines that the advanced directive is valid by the client signature on the form, two signatures on the form, and indication of a durable power of attorney. If the healthcare provider is following the advanced directive it does not support the validity. The family wanting ventilation does not support the advanced directive as no life support is specifically stated in the advanced directive.

A nurse who is not assigned to care for a client may access the client's electronic health record in which circumstance?

Correct response: The nurse is reporting lab results to the Code Blue team during resuscitation. Explanation: Although not directly assigned to the client's care, the nurse is participating on the team providing emergency resuscitative care when relaying information from the client's health record. In order to gain access to the client's health information, regardless of employment at the hospital where the client was receiving care, the nurse would need to sign the HIPPA releases, just as any parent would need to do. While the nurse may have provided care to a client in the past, the nurse does not have permission to access the client's records on the current admission if not assigned to provide care. Although the neighbor gave verbal permission to access the records, the permission is not in writing and therefore would be unauthorized access by the nurse.

A client, recovering from a spinal cord injury, has a great deal of spasticity. Which medication would the nurse anticipate to relieve spasticity?

Correct response: baclofen Explanation: Baclofen is a skeletal muscle relaxant used to decrease spasms. It may be given orally or intrathecally. Hydralazine is an antihypertensive and afterload-reducing agent. Lidocaine is an antiarrhythmic and a local anesthetic agent. Methylprednisolone is an anti-inflammatory drug used to decrease spinal cord edema in the acute phase.

The nurse is interested in serving as an expert nursing witness in the court of law. What actions will support the nurse expert witness role? Select all that apply.

Correct response: practicing in multiple clinical experiences achieving a solid educational background Explanation: An expert nurse witness will have strong clinical experiences and a solid nursing educational background. An advanced nursing degree is not required for an expert nurse witness. Researching legal cases and working as a paralegal will provide law insight but is not required for the nurse expert role.

The nurse is working on a pediatrics unit. Which intervention for a 6-year-old who still wets the bed would be best assigned to the unlicensed assistive personnel (UAP)?

Correct response: reminding the child to use the bathroom before going to bed Explanation: Reminding the child about something that has already been taught is within the scope of practice of the UAP. A licensed practical/vocational nurse (LPN/VN) could administer the oral medication. Teaching and discussion of other strategies for dealing with bed-wetting require additional education and are more appropriate to the scope of practice of the registered nurse.

Which task(s) would a nurse choose to delegate to an unlicensed assistive personnel (UAP)? Select all that apply.

Correct response: taking a client's vital signs documenting a client's oral intake performing a blood glucose check assisting with I.V. insertion Explanation: Registered nurses are responsible for all phases of the nursing process. These responsibilities include planning bathing techniques. A nurse may delegate tasks such as taking vital signs, documenting intake and output, assisting with I.V. insertion, and performing blood glucose checks if the nurse follows the rights of delegation. The rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows up on the task after it has been completed).

A nurse who is a case manager is responsible for assigning client care to unlicensed assistive personnel (UAPs). The nurse is planning the care for a new pediatric client who requires several treatments. Which UAP will the nurse assign to care for the new client?

Correct response: the UAP who has independently provided the same treatments to clients in the past Explanation: The nurse is accountable for the assignment of tasks to UAPs. The nurse must ensure that the care being assigned is consistent with the UAP's level of knowledge, skill, and judgment. Assignments must also consider the UAP job description, agency policy, legislation, and client need. Friendliness and time management skills are traits that may enhance delivery of care, but they do not meet the requirements for safely assigning client care. Supervised practice does not ensure competency.

A client is resting in bed. The nurse visits the client to reassess the client's pain. The nurse notices that a visitor is in the room and is touching the client in various places on the client's body. The nurse understands that this type of practice is called:

Correct response: therapeutic touch. Explanation: Therapeutic touch uses energy fields that surround and penetrate the human body with the conscious intent to help or heal. Herbal medicine includes oral or topical supplements. Traditional Chinese medicine uses the balance of yin and yang.

A terminally ill client in hospice care is experiencing nausea and vomiting because of a partial bowel obstruction. To respect the client's wishes for palliative care, what can the nurse recommend that the client use?

Correct response: a clear liquid diet Explanation: The use of diet modification is a conservative approach to treat the terminally ill or hospice clients who have nausea and vomiting related to bowel obstruction. Osmotic laxatives would be harder for the client to tolerate. An NG tube is more aggressive and invasive. IV antiemetics are also invasive. The hospice philosophy involves comfort and palliative care for the terminally ill.

A registered nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which client's care will the nurse safely delegate to the UAP?

Correct response: a client diagnosed with renal calculi who is encouraged to ambulate four times daily Explanation: The ambulation of the client diagnosed with renal calculi may safely be delegated to the UAP. The registered nurse should care for the clients with a suprapubic catheter draining burgundy-colored urine. The client returning from anesthesia unit requires assessment, and assessment is not within the scope of practice for the UAP. The UAP would also not be permitted to perform bladder irrigation.

A registered nurse (RN) is assigning tasks to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the client care team. Which task is restricted in terms of which care team member it could be delegated to? Select all that apply.

Correct response: administering oral pain medication to a postoperative client assessing a client who just returned from cardiac catheterization taking the health history of a newly admitted client Explanation: Although RNs perform many tasks that overlap with those of other caregivers, the RN has a specific role within the nursing process. The RN may not delegate assessment of new or unstable clients. During the assessment step of the nursing process, the RN obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating corresponding nursing diagnoses. In addition, the RN cannnot delegate administration of medications to the UAP. Assisting a client to the bathroom and providing oral care could be performed by any of these three care team members.