Unit 8 Notecards:
The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift
1. As-needed medications given that shift R: The nursing hands-off (end-of-shift) report needs to be an efficient and accurate account of the client's condition during the last shift. It needs to include pertinent information about the client, such as tests and treatments; as-needed medications given or therapies performed during the past 24 hours, including the client's response to them; changes in the client's condition; scheduled tests and treatments; current problems; and any other special concerns. It is not necessary to include the total number of medications given or a list of all the tests and treatments that the client has had since admission. Only significant vital signs need to be included.
A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire
1. Autocratic R: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to the work group.
Which guidelines should the nurse follow when performing narrative documentation? Select all that apply. 1. Date and time entries. 2. Sign and title each entry. 3. Avoid judgmental and evaluative statements. 4. Document judgmental information completely. 5. Do not leave blank spaces on documentation forms.
1. Date and time entries. 2. Sign and title each entry. 3. Avoid judgmental and evaluative statements. 5. Do not leave blank spaces on documentation forms. R: The nurse always dates and times entries and signs and titles each entry. The nurse provides objective, factual, and complete documentation and avoids subjective, judgmental, and evaluative statements. Quotes are used to relate what the client actually said. The nurse avoids leaving blank spaces on documentation forms because this allows for an area in which notes can be entered by others at a later time. The recording of information in the client's record must be sequential.
The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.
1. Decline to sign the will. R: Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility in which the client is receiving care.
A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next? 1. Place dry, sterile dressings over the eyes of the deceased. 2. Call the National Donor Association to confirm that the client is a donor. 3. Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes. 4. Ask the wife to obtain the legal documents regarding organ donation from the lawyer.
3. Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes. R: When a corneal donor dies, antibiotic eyedrops may be prescribed and instilled. The eyes are closed and a small ice pack is placed on the closed eyes. The head of the bed is raised to 30 degrees to prevent edema. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Option 1 is incorrect because dry dressings are not applied. Some organ donation protocols indicate using normal saline-moistened gauze. Option 2 is not an immediate action. In addition, the client should have a signed donor card, living will, or an organ donor-identified driver's license stating his or her wishes. Additional legal documentation should not be required. Agency procedures regarding donor care should be followed.
A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action? 1. Discuss the client's request with the family. 2. Document the client's request in the client's record. 3. Notify the health care provider of the client's request. 4. Conduct a client conference to share the client's request.
3. Notify the health care provider of the client's request. R: External cardiac massage is one type of treatment that a client can refuse. The appropriate initial action is to notify the health care provider (HCP) because a written "do not resuscitate" (DNR) prescription from the HCP must be present. The DNR prescription must be reviewed or renewed on a regular basis, per agency policy.
The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which is a characteristic of this type of nursing model of practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients.
3. Nursing staff are led by the nurse when providing care to a group of clients. R: In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.
The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and malaise 2. A client who twisted her ankle when she fell while in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce R: In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.
The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence. Based on the nurse practice act, the observing nurse should plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor.
4. Report the information to a nursing supervisor. R: Nurse practice acts require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing. Options 1 and 2 are inappropriate. Option 3 may cause a conflict.
An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent.
4. Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent. R: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance 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 instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.