Saunders - Ethical & Legal Questions w/ Rationale

The nurse manager is planning to implement a change in the nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance during the change process. Which primary technique should the nurse use in implementing this change? 1.Introduce the change gradually. 2.Use coercion to implement the change. 3.Manipulate the participants in the change process. 4.Confront the individuals involved in the change process.

Answer: 1. Introduce the change gradually. Rationale: The primary technique that can be used to handle resistance to change during the change process is to introduce the change gradually. Coercion can be used to decrease resistance to change, but it is not always a successful technique for managing resistance. Manipulation usually involves a covert action, such as leaving out pieces of vital information that the participants might receive negatively. It is not the best method of implementing a change. Confrontation is an important strategy used when resistance occurs.

The nurse is acting in the role of client advocate in which situations? (Select all that apply) 1.Promoting client comfort 2.Demonstrating mutual respect for all nurses 3.Questioning primary health care provider prescriptions 4.Supporting a client decision regarding a health care choice 5.Speaking at a continuing education offering in the community

Answer: 1.Promoting client comfort 3.Questioning primary health care provider prescriptions 4.Supporting a client decision regarding a health care choice Rationale: A client advocate is a person who speaks out for or supports the best interests of the client. This includes encouraging independence in addition to speaking for the client. Demonstrating mutual respect for all nurses and speaking at a continuing education offering does not relate to client advocacy.

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? 1.Libel 2.Slander 3.Assault 4.Negligence

Answer: 2. Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? 1.Wash the burn site. 2.Apply the medication with a sterile gloved hand. 3.Apply saline-soaked dressings over the medication. 4.Apply 1/16-inch (1.5-mm) film directly to the burn sites.

Answer: 3. Apply saline-soaked dressings over the medication. Rationale: Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in second- and third-degree burns when bacterial resistance to other agents is a potential problem. The burn site is washed before medication application. A film of 1/16 inch (1.5 mm) is applied directly to the burn using a sterile gloved hand. Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned.

The community health nurse is working with disaster relief personnel after a hurricane that ruined many homes in the local community. The nurse is working to find housing for the survivors and is organizing counseling services. Which prevention level do the nurse's actions represent? 1.Primary 2.Secondary 3.Tertiary 4.Quaternary

Answer: 3. Tertiary Rationale: Tertiary prevention involves reduction of the amount and degree of disability, injury, or damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of the crisis during the crisis itself. There is no known quaternary care prevention level.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found lying on the floor. 4.The client became restless and tried to get out of bed.

Answer: 3. The client was found lying on the floor. Rationale: The incident report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1.Performing a procedure without consent 2.Threatening to give a client a medication 3.Telling the client that he or she cannot leave the hospital 4.Observing care provided to the client without the client's permission

Answer: 4. Observing care provided to the client without the client's permission Rationale: Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

Laptop computers have been purchased by a community hospital to be used in the nursing units for documentation. The nurse educator at the hospital plans in-service educational sessions regarding the use of the computers and the new documentation system. The nurse educator anticipates some resistance to the use of the computers and should plan to best deal with this difficulty by doing what? 1.Ignoring the resistance 2.Discarding all paper-type documentation forms 3.Demanding that the nurses use the new computer system 4.Allowing the nurses extra time to work with the new computer system

Answer: 4.Allowing the nurses extra time to work with the new computer system Rationale: Allowing the nurses extra time to work with the new computer system will alleviate anxiety. Ignoring the issue will not address the problem. Discarding all paper-type documentation forms may cause anxiety in the nurses, particularly if the nurses are uncomfortable with the computer system. Demanding that the nurses use the new computer system may cause resentment and resistance.

Which identifies accurate nursing documentation notation(s)? (Select all that apply) 1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Answer: 1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? 1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found lying on the floor. 4.The client became restless and tried to get out of bed.

Answer: 3. The client was found lying on the floor. Rationale: The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? (Select all that apply) 1."This document is a separate document from my final will." 2."This document is strictly for indicating if I want to be resuscitated." 3."I need to have my family sign this document in case my condition worsens." 4."This document describes the kind of treatment I want depending on how sick I am." 5."This document tells what I want and gives medical power of attorney to my doctor."

Answer: 1. "This document is a separate document from my final will." 4. "This document describes the kind of treatment I want depending on how sick I am." Rationale: An advance directive describes the specific medical treatment that a client wants if he or she is unable to make decisions about care. An advance directive is a separate document from the final will. The family does not need to sign an advance directive. Medical power of attorney is a type of advance directive but requires separate documentation. A do not resuscitate order is a type of advance directive, but an advance directive encompasses additional information. Therefore, options 2, 3, and 5 are incorrect.

A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? 1.Assault 2.Battery 3.Slander 4.Invasion of privacy

Answer: 1. Assault Rationale: Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result from the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.

The nurse calls a client's primary health care provider (PHCP) to report that the client, who has heart failure, is demonstrating increased wheezes on lung auscultation and dyspnea. The PHCP is in a hurry because of involvement in a critical care situation in the hospital emergency department and gives the nurse a telephone prescription for furosemide. Afterwards, the nurse realizes that the route of the medication is unclear. Which action by the nurse is the most appropriate? 1.Call the PHCP who gave the telephone prescription and clarify the prescription. 2.Call the nursing supervisor for assistance in determining the route of the medication. 3.Administer the medication by the intravenous route because this route usually is used for clients with heart failure. 4.Administer the medication by the oral route, and clarify the prescription once the PHCP has finished addressing the critical care issue in the emergency department.

Answer: 1. Call the PHCP who gave the telephone prescription and clarify the prescription. Rationale: Telephone prescriptions involve a PHCP stating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating it clearly and precisely to the PHCP. The nurse then writes the prescription on the PHCP's prescription sheet. Under no circumstances would the nurse try to interpret an unclear prescription or administer a medication by a route that was not prescribed. The nurse must call the PHCP who gave the telephone prescription and clarify the prescription.

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially? 1.Contact the client's primary health care provider (PHCP). 2.Call the client's family to arrange for transportation. 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

Answer: 1. Contact the client's primary health care provider (PHCP). Rationale: In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release, unless they pose an immediate danger to themselves or others, in which case the admission could become involuntary depending on the circumstances and regulations in that area and facility. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? 1.Contact the nursing supervisor. 2.Administer the dose prescribed. 3.Hold the medication until the PHCP can be contacted. 4.Administer the recommended dose until the PHCP can be located.

Answer: 1. Contact the nursing supervisor. Rationale: If the PHCP writes a prescription that requires clarification, the nurse's responsibility is to contact the PHCP. If there is no resolution regarding the prescription because the PHCP cannot be located or because the prescription remains as it was written after talking with the PHCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? 1.Contact the nursing supervisor. 2.Administer the dose prescribed. 3.Hold the medication until the PHCP can be contacted. 4.Administer the recommended dose until the PHCP can be located.

Answer: 1. Contact the nursing supervisor. Rationale: If the PHCP writes a prescription that requires clarification, the nurse's responsibility is to contact the PHCP. If there is no resolution regarding the prescription because the PHCP cannot be located or because the prescription remains as it was written after talking with the PHCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

While eating lunch in the hospital cafeteria, a nursing student overhears 2 nurses talking about a client. Which is the important information for the nurses to remember when talking about the client? 1.Talking about clients in public places is a violation of the client's confidentiality. 2.The client's rights to confidentiality do not apply to the break time of employees. 3.It is acceptable for the nurses to talk about a client because they are on the same treatment team. 4.The nurses taking care of the client should not share information with each other that the client has told them separately.

Answer: 1. Talking about clients in public places is a violation of the client's confidentiality. Rationale: Although it is acceptable for the nurses on the same treatment team for a client to discuss his or her treatment, it is not appropriate to do so in the cafeteria or any other place, particularly when others could potentially hear this conversation. The nurse cannot violate confidentiality during the professional's personal time. There is not a time during which it is acceptable to violate confidentiality except in the case of a life-or-death emergency.

The nurse witnesses an automobile crash on a highway and stops to provide assistance to the victim. The nurse notes that the client has sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the crash. Which is accurate regarding the nurse's immunity from this suit? 1.The Good Samaritan law will protect the nurse. 2.The Good Samaritan law will not protect the nurse. 3.The Good Samaritan law protects laypersons but not professional primary health care providers (PHCPs). 4.The Good Samaritan law will provide immunity from the suit, even if the nurse has accepted compensation for the care provided.

Answer: 1. The Good Samaritan law will protect the nurse. Rationale: A Good Samaritan law is passed by a state legislature to encourage nurses and other PHCPs to provide care to a person when an accident, emergency, or injury occurs without fear of being sued for the care provided. Its protection lies in the inability to sue the nurse or other PHCP for negligence in the care provided at the scene of the accident or during the emergency, even if further injury occurred because of the PHCP's care. Called immunity from suit, this protection usually applies only if all conditions of the law are met, such as that the PHCP received no compensation for the care provided and the care given was not willfully and wantonly negligent.

Which identifies accurate nursing documentation notations? (Select all that apply) 1.The client is resting in bed with the eyes closed. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Answer: 1.The client is resting in bed with the eyes closed. 2.Abdominal wound dressing is dry and intact without drainage. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

The registered nurse (RN) is beginning a new job in a clinic and attends an orientation session. After the session, another new employee asks the RN to describe case management, a component of the discussions in the orientation session, because the employee did not clearly understand the concept. Which statement made by the nurse is the most appropriate? 1."Case management is an important concept, but it doesn't promote appropriate use of personnel." 2."Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." 3."Case management saves money for the institution because clients with similar problems are all treated in the same manner." 4."Case management requires an experienced nurse because it represents a primary health prevention focus and is managed by a single nurse."

Answer: 2. "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." Rationale:Case management represents an interdisciplinary health care delivery system that promotes appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcomes of client care. The remaining options are inaccurate statements regarding case management.

A client is scheduled for surgery, and the surgeon has explained the procedure and is about to obtain informed consent. Which statement by the client would indicate to the nurse that the client needs further teaching before giving informed consent to the procedure? 1."If I don't have this surgery, then the tumor will grow." 2."I know my surgeon explained it, but I still don't know why surgery is needed." 3."You said my surgeon will remove the tumor but will not be removing the entire breast." 4."I'll have some pain after the surgery, but it should get better with that tumor gone."

Answer: 2. "I know my surgeon explained it, but I still don't know why surgery is needed." Rationale: Informed consent must be obtained before surgery can be legally performed. The nurse acts as an advocate to make sure that the client understands what the primary health care provider has explained about the surgery. The client must receive information about the purpose of the surgery, other options if surgery is not done, risks of surgery, and benefits of surgery. Options 1, 3, and 4 identify an understanding by the client, whereas option 2 indicates that the client needs more information.

A woman with left-sided weakness needs assisted living. The woman's family plans to sell her home to pay for assisted living, but the woman refuses to sell because she feels that her family should pay the expenses. What should the nurse do at this time? 1.Carefully explain the woman's wishes to the family. 2.Ask the woman to share experiences about the house. 3.Arrange a meeting between the children and the woman. 4.Suggest using a power of attorney to deal with the children.

Answer: 2. Ask the woman to share experiences about the house. Rationale: The nurse should ask the woman to share experiences about the house and act as her advocate. Listening to the woman helps the nurse to gather additional data, enhance the therapeutic relationship by preserving autonomy, and possibly help solve the problem. The woman has not asked the nurse to intervene on her behalf with the family, so explaining the woman's wishes to the family is not indicated. Also, arranging a meeting ignores her autonomy and forces the woman and family to confront one another. The nurse only arranges a meeting after the woman requests or agrees to it. Suggesting a power of attorney is counterproductive to advocacy.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1.Refuse to float to the ICU based on lack of unit orientation. 2.Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. 3.Ask the nursing supervisor to review the hospital policy on floating. 4.Submit a written protest to nursing administration, and then call the hospital lawyer.

Answer: 2. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. Rationale: Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1.Refuse to float to the ICU based on lack of unit orientation. 2.Clarify with the team leader to make a safe ICU client assignment. 3.Ask the nursing supervisor to review the hospital policy on floating. 4.Submit a written protest to nursing administration, and then call the hospital lawyer.

Answer: 2. Clarify with the team leader to make a safe ICU client assignment. Rationale: Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1.Call the client's family to arrange for transportation. 2.Contact the client's primary health care provider (PHCP). 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

Answer: 2. Contact the client's primary health care provider (PHCP). Rationale: In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.

After initial assessment the nurse determines the need to place a restraint on a client. The client refuses application of the restraint. What is the best nursing action for this client? 1.Apply the restraint anyway. 2.Contact the primary health care provider (PHCP). 3.Compromise with the client and then apply the restraint. 4.Medicate the client with a sedative and then apply the restraint.

Answer: 2. Contact the primary health care provider (PHCP). Rationale: The use of restraints needs to be avoided if possible. If the nurse determines that a restraint is necessary, this should be discussed with the family and a prescription needs to be obtained from the PHCP. The PHCP's prescription protects the nurse from liability. The nurse should explain to the client and family the reasons why the restraint is necessary, the type of restraint selected, and the anticipated duration of restraint. If the nurse applied the restraint on a client who was refusing, the nurse could be charged with battery. Compromising with the client is unethical.

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? (Select all that apply) 1.Document a late entry in the client's record. 2.Draw 1 line through the error, initialing and dating it. 3.Try to erase the error for space to write in the correct data. 4.Use whiteout to delete the error to write in the correct data. 5.Write a concise statement to explain why the correction was needed. 6.Document the correct information and end with the nurse's signature and title.

Answer: 2. Draw 1 line through the error, initialing and dating it. 6. Document the correct information and end with the nurse's signature and title. Rationale: If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing 1 line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary.

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? (Select all that apply) 1.Libel 2.Battery 3.Assault 4.Slander 5.False imprisonment

Answer: 2.Battery 3.Assault 5.False imprisonment Rationale: False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the client.

The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply. 1.Respect assumptions. 2.Monitor language and tone. 3.Adopt a "need-to-know" policy. 4.Be alert to the presence of gossip. 5.Try to limit the use of obscene language. 6.Hold yourself and one another accountable.

Answer: 2.Monitor language and tone. 3.Adopt a "need-to-know" policy. 4.Be alert to the presence of gossip. 6. self and one another accountable. Rationale: Some ethical strategies to use when preparing a change-of-shift report include the following: monitoring language and tone, adopting a "need-to-know" policy, being alert to the presence of gossip, and holding oneself and one another accountable. Respecting assumptions and limiting the use of obscene language are not appropriate strategies. A change-of-shift report is given from 1 caregiver to another caregiver who is taking on responsibility for the client's care to ensure continuity of care.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? (Select all that apply) 1.Complete and file an occurrence report. 2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information.

Answer: 2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information. Rationale: Electronic health records (EHR) will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error in the MAR, the nurse should follow agency policies to correct the error. In the MAR, the nurse can click on the entry (usually right-click) and modify it to reflect the corrected information. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication, to validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the EHR. An occurrence report is not necessary in this situation.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1.Call the police. 2.Cut up the photograph and throw it away. 3.Call the nursing supervisor and report the incident. 4.Call the laboratory and ask for the name of the individual who sent the photograph.

Answer: 3. Call the nursing supervisor and report the incident. Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1.Call the police. 2.Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the occurrence. 4.Call the laboratory and ask for the name of the individual who sent the photograph.

Answer: 3. Call the nursing supervisor and report the occurrence. Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker and is an abusive behavior. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

he nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the coworker in the medication room until help is obtained.

Answer: 3. Call the nursing supervisor. Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.

The nurse manager is reviewing documentation describing a client's progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The nurse manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control during the prior 48 hours. Who should the nurse manager contact next? 1.Assigned nurse, to increase client care interventions 2.Family, to determine what is wrong and provide suggestions 3.Case manager, to determine whether the predicted variance has been negotiated with the health insurer 4.Primary health care provider (PHCP) and assigned nurse, to determine measures to discharge the client

Answer: 3. Case manager, to determine whether the predicted variance has been negotiated with the health insurer Rationale: Option 3 is correct because the nurse manager of the unit is accountable for cost recovery. In this situation, documentation is complete; however, each client's progress along the critical path can vary. Option 1 is incorrect because there is no indication that the care is ineffective. There is no need to contact the PHCP and assigned nurse (option 4) or the family (option 2) because the subject is cost recovery. The nurse manager works to be certain that the costs incurred will be negotiated with the insurer at the time that the variance is detected and that the hospital is paid for the costs of providing care longer than the period defined by the critical path.

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1.The informed consent does not need to be obtained. 2.The informed consent should be obtained from the family. 3.The informed consent needs to be obtained from the client. 4.The primary health care provider will provide the informed consent.

Answer: 3. Informed consent needs to be obtained from the client. Rationale: Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.

The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Which is important information for the nurse to remember? 1.That an informed consent does not need to be obtained 2.That an informed consent should be obtained from the family 3.That an informed consent needs to be obtained from the client 4.That the primary health care provider will provide the informed consent

Answer: 3. That an informed consent needs to be obtained from the client Rationale: Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client. Therefore, options 1, 2, and 4 are incorrect.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family.

Answer: 3. Transport the victim to the operating room for surgery. Rationale: In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1. Using sterile sheets and linens 2.Performing strict hand-washing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

Answer: 3. Wearing gloves and a gown only when giving direct care to the client Rationale: In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1."Autonomy is the fundamental right of each and every client." 2."A client's rights are guaranteed by both state and federal laws." 3."Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4."Regardless of the client's condition, all nurses have the duty to value client rights."

Answer: 3."Being respectful and concerned will ensure that I'm attentive to my clients' rights." Rationale: The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights. While it is true that autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for the concept.

The experienced nurse is observing a newly hired graduate nurse count opioids as part of the orientation process. The experienced nurse determines that the newly hired nurse needs further teaching about the procedure for counting opioids when which statement is made? 1."Any discrepancies in a count will be reported immediately." 2."I will record each dispensing of an opioid on the special opioids inventory record." 3."If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift." 4."Opioids will be counted each time one is removed from the drawer and at the end and beginning of each shift."

Answer: 3."If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift." Rationale: If the nurse gives a portion of a premeasured dose of a controlled substance, a second nurse witnesses disposal of the unused portion. Both nurses must sign the form. Leftover portions of an opioid are not saved for use at a later time. The statements in the remaining options are accurate.

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response by the nurse is most appropriate? 1."I will need to sign as a witness to your signature." 2."It is your responsibility to find a witness on your own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the nursing supervisor for assistance regarding your request."

Answer: 4. "I will call the nursing supervisor for assistance regarding your request." Rationale: Living wills are required to be in writing and signed by the client. The client's signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including the nurse of a facility where the declaring is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

While making rounds a client asks the nurse, "What's wrong with that lady in the room next to me? She cries out all night long, and I hope she is okay." What is the nurse's best response? 1."She's okay; she just gets confused at night." 2."I'm not allowed to say anything to you about her." 3."She has Alzheimer's disease and gets very upset because she is not home." 4."I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients."

Answer: 4. "I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients." Rationale: To keep client information confidential, the nurse should not discuss any aspects of a client's care with other clients or with staff who are not involved in the client's care. Simply saying "I'm not allowed" is correct but abrupt. The correct answer acknowledges the client's concern yet preserves the other client's privacy. Relaying any information about the other client would be a violation of that client's privacy and would not be in compliance with the Health Insurance Portability and Accountability Act.

A primary health care provider (PHCP) asks the nurse to discontinue tube feeding in a client who has a terminal condition. The PHCP tells the nurse that the request was made by the client's spouse and children. What should the nurse check for first before carrying out the prescription? 1.Court approval to discontinue the treatment 2.Approval by the institutional ethics committee 3.A written prescription by the PHCP to remove the tube 4.Authorization by the family to discontinue the treatment

Answer: 4. Authorization by the family to discontinue the treatment Rationale: The family or a legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the PHCP writes the prescription. Generally, the family makes decisions in collaboration with PHCPs and other health care workers and with other trusted advisers. Therefore, the remaining options are incorrect. Court approval may be necessary if a conflict exists or if there is no legal guardian to make the decision. The institutional ethics committee presents acceptable choices or options, but approval by this committee is not necessary.

The nurse employed in a surgical unit in a hospital arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is most appropriate? 1.Refuse to float to pediatrics. 2.Convince another nurse to float to the pediatric unit. 3.Tell the supervisor that she needs to go home because of illness. 4.Call the nursing supervisor to discuss the request to report to pediatrics.

Answer: 4. Call the nursing supervisor to discuss the request to report to pediatrics. Rationale: Floating may be acceptable legal practice used by hospitals to solve their understaffing problems, enhance efficiency, and reduce staffing costs. Usually the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or unless the nurse can prove lack of knowledge for the performance of assigned tasks. When met with this situation, the nurse should set priorities and identify potential areas of harm to the client. Nurses must be aware of state statutes and case law when asked to perform services outside of their usual area of practice. The nurse should never perform tasks or render services when he or she lacks the knowledge and skill to act competently. It is not appropriate to attempt to convince another nurse to go to the pediatric unit. Option 3 also is an inappropriate action. Among the options presented, it is most appropriate to discuss the situation with the supervisor.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1.Ignore the resistance. 2.Exert coercion on the AP. 3.Provide a positive reward system for the AP. 4.Confront the AP to encourage verbalization of feelings regarding the change.

Answer: 4. Confront the AP to encourage verbalization of feelings regarding the change. Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically.

A homeless client comes to the emergency department complaining of severe pain in the toes of both feet. On assessment, it is found that all of the toes are black in color and that amputation is necessary. The client refuses the surgery and insists on returning to street living. Which describes the next appropriate action to take? 1.Obtain a court order for the surgical procedure. 2.Restrain the client and transport to the operating room for surgery. 3.Call the police to identify the client and to arrest the client until permission for surgery is granted. 4.Discuss the surgical procedure and its purpose with the client, and encourage the client to talk about concerns and feelings.

Answer: 4. Discuss the surgical procedure and its purpose with the client, and encourage the client to talk about concerns and feelings. Rationale: In general, there are only 2 situations in which the informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. In this situation, informed consent is necessary if the client is mentally competent. Option 1 is unnecessary and not the next appropriate action. Restraining the client and having the client arrested violates client rights. The next appropriate action to take is to explore and determine the reasons why the client is refusing surgery and to allow the client an opportunity to express any concerns.

The nurse has made an error in documenting an assessment finding in the client's record. What action should the nurse take to correct the error? 1.Write the late entry in the client's record. 2.Erase the error and rewrite the correct data. 3.Use white correction fluid or tape to cover the error and write in the correct assessment findings. 4.Draw a line through the error, initial and date the line, and then provide the correct information.

Answer: 4. Draw a line through the error, initial and date the line, and then provide the correct information. Rationale: If the nurse makes an error in documenting in the client's record, the nurse should follow agency policies to correct the error. This includes drawing 1 line through the error, initialing and dating the line, and then providing the correct information. Erasing data from the client's record and using white correction fluid or tape are prohibited. A late entry is used to document additional information not remembered at the initial time of documentation. Procedures for correcting an error via the use of electronic documentation may be different, and the nurse should follow agency guidelines.

The nurse suspects that a client is not fully aware of the implications of a procedure and the client is about to sign an informed consent. What action would be most appropriate for the nurse to take? 1.Ask a family member to sign the consent because the client seems unsure at this time. 2.Tell the client that he can ask the primary health care provider (PHCP) for more details when he gets to the operating room. 3.Ask the client if the PHCP explained the procedure before obtaining the signature. 4.Inform the PHCP that the client does not appear to fully understand the procedure and withhold obtaining the signature.

Answer: 4. Inform the PHCP that the client does not appear to fully understand the procedure and withhold obtaining the signature. Rationale: The only safe action is to inform the PHCP that the client does not appear to fully understand the procedure and withhold obtaining the signature. Asking the client if the PHCP explained the procedure is insufficient because the client may give a "yes" or "no" answer to the question and may want to sign the consent without adequate information. It is never appropriate to defer the signature to a family member unless that person has legal authorization to sign for the client. It is unsafe to tell the client that he can ask the PHCP for more details when he gets to the operating room because he may have received sedating medications.

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse should take which priority action? 1.Send the client to surgery without the consent form being signed. 2.Have the hospital chaplain sign the informed consent immediately. 3.Notify the primary health care provider (PHCP) to obtain a court order for the surgery. 4.Obtain telephone consent from the family member witnessed by 2 authorized individuals.

Answer: 4. Obtain telephone consent from the family member witnessed by 2 authorized individuals. Rationale: Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by 2 authorized individuals who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under sedation. In emergencies, the client may be unable to sign and family members may not be available. In this type of situation, the PHCP is legally permitted to perform surgery without consent. Options 1 and 2 are not appropriate. In addition, actions that delay treatment in an emergency are not appropriate.

The nurse gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the primary health care provider to report the occurrence. Which action should the nurse manager anticipate will take place next? 1.The incident will be reported to the board of nursing. 2.The incident will be documented in the personnel file. 3.The error will result in suspension and be written in the annual performance appraisal. 4.The incident report will be used to review quality of care and determine potential risks.

Answer: 4. The incident report will be used to review quality of care and determine potential risks Rationale: Documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result is maintained by the institution or agency and allows the nurse and administration to review quality of care and determine any potential risks. Based on the information provided in the question, the nurse's error will not result in suspension and be written in the annual performance appraisal, nor will it be documented in the personnel file. The error and the situation presented in the question are not reasons for notifying the board of nursing.

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1."Oh, really? I will discuss this situation with your son." 2."Let's talk about the ways you can manage your time to prevent this from happening." 3."Do you have any friends who can help you out until you resolve these important issues with your son?" 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

Answer: 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1."Oh, really? I will discuss this situation with your son." 2."Let's talk about the ways you can manage your time to prevent this from happening." 3."Do you have any friends who can help you out until you resolve these important issues with your son?" 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

Answer: 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma? (Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used.) 1.Evaluate the action. 2.Verbalize the problem. 3.Negotiate the outcome. 4.Consider possible courses of action. 5.Gather all information relevant to the case. 6.Examine and determine one's own values on the issues.

Answer: 5 - 6 - 2 - 4 - 3 - 1 Rationale: Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether the issue involves an ethical dilemma and gathers information that is relevant to the case. Second, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing confidence in her or his own point of view with deep respect for the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that would allow the nurse to preserve integrity yet allow the family to determine when the client should be informed of the tragic loss. Finally, the nurse evaluates the action.

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1."I cannot discuss any client situation with you." 2."If you want to know about Carol, you need to ask her yourself." 3."Only because you're worried about a friend, I'll tell you that she is improving." 4."Being her friend, you know she is having a difficult time and deserves her privacy."

Answer: 1. "I cannot discuss any client situation with you." Rationale: The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.

The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate should indicate to the nurse that there is a need for further teaching? 1."I don't think you need to do that." 2."Tell me about making that decision." 3."I would like to be sure I understood." 4."When did you first notice you felt that way?"

Answer: 1. "I don't think you need to do that." Rationale: The correct option is very clearly a judgmental response, as it specifically casts judgment on an action. The remaining options seek to explore with the client as opposed to commenting on or giving advice.

The nurse is working at a computer in the nurses' station when the charge nurse from another nursing unit approaches and asks about the condition of the client in room 432, stating, "The client is my neighbor and I want to check on her." The nurse should make which most appropriate response? 1."I'm sorry, I cannot tell you." 2."The condition of the client in room 432 is good." 3."You can get the information from the client's chart." 4."I don't think you should be asking me that question."

Answer: 1. "I'm sorry, I cannot tell you." Rationale: The nurse has a legal obligation to protect the client's right to confidentiality and legally cannot share any information about the client with a neighbor. In addition, it is only on a need-to-know basis that client information should be shared with other health care personnel who are directly involved in the client's care. Option 1 is factual and honest. Options 2 and 3 inappropriately provide client information. Although option 4 is correct, it is an inappropriate statement and is challenging.

The nurse is caring for a client who has just returned from having a right-sided renal biopsy. Which action by the assistive personnel (AP) requires immediate follow-up by the nurse? 1.Obtaining the client's vital signs 2.Positioning the client on the left side 3.Providing the client with reading materials 4.Assisting the client to drink sips of fluid as prescribed

Answer: 2. Positioning the client on the left side Rationale: A client who has undergone a renal biopsy should be positioned on the affected side or back (if prescribed); positioning on the affected side maximizes pressure to the area to prevent bleeding. Options 1, 3, and 4 are correct interventions.

A client refuses to take a medication. Which is the most therapeutic response by the nurse? 1."I'll come back later to see if you have changed your mind." 2."You don't have to take the medication if you don't want to." 3."This medication is going to help you get better, so why don't you go ahead and take it?" 4."Do you want me to call your primary health care provider (PHCP) and tell him you won't take your medication?"

Answer: 2. "You don't have to take the medication if you don't want to." Rationale: The client has the right to refuse medications or any other aspect of therapy. Therefore, the correct option is the therapeutic response. Options 3 and 4 are degrading and scold the client. Although option 1 is a possible choice, it isn't the best or therapeutic one.

The registered nurse (RN) is observing a licensed practical nurse (LPN) who is caring for a client with a uterine tumor who had a vaginal hysterectomy. The RN should intervene if the RN notes the LPN performing which action? 1.Assisting the client to ambulate 2.Elevating the knee gatch on the client's bed 3.Performing range-of-motion exercises to the client's legs 4.Removing the ant-iembolism stockings during morning care

Answer: 2. Elevating the knee gatch on the client's bed Rationale: After a vaginal hysterectomy, the client is at risk for deep vein thrombosis or thrombophlebitis. The nurse should implement measures that prevent this complication. Range-of-motion exercises, anti-embolism stockings, and ambulation are important measures to prevent this complication. Anti-embolism stockings are removed to provide hygiene care and are then replaced. If the RN notes that the LPN used the knee gatch on the bed, the RN should intervene. This action would inhibit venous return, increasing the risk for deep vein thrombosis or thrombophlebitis.

A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action? 1.Using a Z-track method for injection 2.Massaging the injection site after injection 3.Preparing an air lock when drawing up the medication 4.Changing the needle after drawing up the dose and before injection

Answer: 2. Massaging the injection site after injection Rationale: The site should not be massaged after injection because massaging could cause staining of the skin. Z-track technique and an air lock both should be used. Proper technique for administering iron by the IM route includes changing the needle after drawing up the medication and before giving it. The medication should be given in the upper outer quadrant of the buttock, not in an exposed area such as the arms or thighs.

The nurse is caring for a client who has just returned from having a cystoscopy with biopsy. The nurse should intervene if an assistive personnel (AP) is observed taking which action? 1.Obtaining the client's vital signs 2.Assisting the client with repositioning in bed 3.Telling the client that warm sitz baths may be prescribed 4.Insisting that the client ambulate immediately after the procedure

Answer: 4. Insisting that the client ambulate immediately after the procedure Rationale: The client who has undergone a cystoscopy with biopsy should not walk alone immediately after the procedure because orthostatic hypotension may occur. Options 1, 2, and 3 are appropriate. Therefore, the nurse would intervene if the AP is observed insisting that the client ambulate immediately after the procedure.

A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2.Threatening to give a client a medication 3.Telling the client that he or she cannot leave the hospital 4.Observing care provided to the client without the client's permission

Answer: 4. Observing care provided to the client without the client's permission Rationale: Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

The nurse discovers a coworker in the linen closet injecting a medication into the antecubital area. Which most appropriate action should the nurse take? 1.Call the police. 2.Notify security. 3.Call the nursing supervisor. 4.Ignore what was discovered to avoid conflict.

Answer: 3. Call the nursing supervisor. Rationale: The Nurse Practice Act requires reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities as required. Option 4 is an inappropriate action and can affect client safety and safety to others.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1."I will sign as a witness to your signature." 2."You will need to find a witness on your own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the nursing supervisor to seek assistance regarding your request."

Answer: 4."I will call the nursing supervisor to seek assistance regarding your request." Rationale: Instructional directives (living wills) are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the coworker in the medication room until help is obtained.

Answer 3. Call the nursing supervisor. Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This occurrence needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.