4th fundamental exam

When applying heat or cold therapy to a wound, what should the nurse do? a) Leave the therapy on each area no longer than 15 minutes. b) Leave the therapy on each area no longer than 30 minutes. c) When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it. d) When using cold, ensure the temperature is less than 32°F (0°C) before applying it.

ANS: A Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon. Temperatures should be kept between 59°F and 113°F (15°C and 45°C), depending on the type of therapy chosen and what is comfortable to the patient. Temperatures colder or hotter than those recommended can damage tissue.

Which of the following concepts refers to conflicts that arise between two or more ethical principles in patient care scenarios? a) Nursing ethics b) Bioethics c) Ethical dilemma d) Moral distress

ANS: C An ethical dilemma occurs when a choice must be made between two or more equally undesirable actions, and there is no clearly right or wrong option. Moral distress occurs when someone is unable to carry out his or her moral decision. Nursing ethics refers to ethical questions that arise out of nursing practice. Bioethics is a broader field that refers to the application of ethics to healthcare.

The patient experiences extensive third-degree burns. What type of healing does the nurse expect? Healing by: a) Primary intention b) Second intention c) Tertiary intention d) Primary intention if no infection occurs

ANS: C A third-degree burn heals by tertiary intention. Skin grafts would be required to bring edges of granulation tissue together. Wound healing by primary intention occurs when there is minimal or no tissue loss, and edges are well approximated. With a third-degree burn the edges cannot approximate for primary intention healing. Even if no infection occurs, this wound will not heal by primary intention because of deep tissue loss.

A 60-year-old patient with a treatable form of breast cancer has decided not to pursue radiation or chemotherapy. The nurse believes that the patient should be treated. She coerces her into receiving treatment by continuing to remind the patient about her responsibilities for raising her children. What type of behavior has the nurse displayed? a) Nonmaleficence b) Autonomy c) Paternalism d) Beneficence

ANS: C Paternalistic behavior occurs when the nurse thinks she knows what is best for a competent patient and coerces the patient to act as she wishes rather than to act as the patient originally desired. Autonomy refers to a person's right to choose and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

Your patient has a deep wound on the right hip, with tunneling at the 8 o'clock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? a) Alginate dressing b) Dry gauze dressing c) Hydrogel d) Hydrocolloid dressing

ANS: A Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin.

Which is not a professional value identified by the American Association of Colleges of Nursing (AACN)? a) Altruism b) Equality c) Education d) Honesty

ANS: A Altruism is identified as one of the values of nursing identified by the AACN. Equality, education, and honesty are not identified as values by the AACN; however, they have been frequently cited in nursing literature as being important to nursing.

The unit manager stops you in the hallway to discuss your inability to give safe patient care. The conversation is overheard by other nurses. The manager's comments are based on false information reported to her by a patient. This is an example of: a) Collaboration b) Assault and battery c) Slander d) Libel

ANS: C Slander is a spoken form of defamation of character. To establish slander, the comments regarding the person have to be false, communicated or overheard by a third party, and defame the nurse's character. This conversation should occur in a private location; thus, it is not collaboration. Libel is the written form of defamation of character. Assault and battery refers to placing the patient in fear of being harmed and following through with unwelcomed touching.

Before the end of the shift, the nurse records the occurrences for each patient in the electronic medical record. Which statement below indicates that the nurse understands the main principle of accurate charting? a) "Charting communicates to members of the healthcare team the patient's care and responses during my shift." b) "Charting is important so that I may share with the healthcare team my opinions of what happened with the patient." c) "Charting allows the other nurses to understand the patient care provided during my shift." d) "Charting is important to comply with practice guidelines and institutional policies."

ANS: A Accurate charting is needed to clearly communicate the patient's care and responses to other members of the healthcare team, not just the other nurses. This statement reflects the nurse's understanding of this principle. The nurse's opinions are not to be placed in a chart because they are not factual. While charting is important to comply with standards of practice and institutional policy, it is not the main principle of accurate charting.

The nurse is facing a moral dilemma and applies the MORAL model to decision making. After writing down all the possible options to solve the problem, what will the nurse do next? a) Consider all the options and choose the best one. b) Implement the chosen option. c) Evaluate the effectiveness of the action. d) Consider the dilemma and whom it involves.

ANS: A After outlining the options, the next step is resolving the dilemma by choosing the best option. A choice cannot be implemented until an action is chosen. An action cannot be evaluated until an action is chosen and implemented. Considering the dilemma and determining who is involved must precede the step of writing down all possible options.

The nurse on night shift is caring for a patient who is confused and gets out of bed frequently. The nurse pushes him into a chair and states, "Do not get out of this chair or I will tie you up and leave you alone for hours." The nurse's action is an example of: a) Assault and battery b) Libel c) False imprisonment d) Safe nursing practice

ANS: A Assault is putting the patient in fear of harm and battery is touching him without his permission or in a way that is forceful. Pushing the patient into the chair is considered battery; threatening to restrain him and leave him alone for hours is assault. False imprisonment is the restraint of a person without proper legal authorization. The patient was not restrained. This is not an example of safe nursing practice, which would require the nurse to initiate the hospital's fall precaution protocol. Restraints are applies as a last resort. Libel is a verbal or written type of character defamation.

Effective delegation is a vital part of the nurse's responsibilities. What factor should guide the nurse to correctly delegate a nursing task? a) The education and experience of the delegatee b) The job description of the delegatee c) The patient request for the delegatee d) The staffing levels on a unit

ANS: A Delegation is a vital component of nursing care; the nurse must know the educational level and experience of the person being delegated a task. This enables the nurse to accurately align the patient care needs with the patient assignments. Once the nurse knows this, patient care assignments can be given with consideration to patient requests and staffing levels on the unit. The delegatee's job description can provide insight into his scope of responsibilities, but the nurse must base delegation on the skill level and experience of the delegate.

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? a) Partial-thickness wound b) Penetrating wound c) Superficial wound d) Full-thickness wound

ANS: A Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

Pressure ulcers are directly caused by which of the following conditions at the site? a) Compromised blood flow b) Edema c) Shearing forces d) Inadequate venous return

ANS: A Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area as a result of pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.

Why is the information obtained from a swab culture of a wound limited? a) A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria. b) A negative culture may not indicate infection because chronic wounds are often colonized with bacteria. c) Most wound infections are viral, so the swab culture would not be indicative of a wound infection. d) A swab culture result does not include bacterial sensitivity information necessary to provide treatment.

ANS: A The information obtained from a swab culture is limited because a positive culture may not indicate infection. Chronic wounds are often colonized with bacteria, but this does not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider.

A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation? a) Disciplinary action against the nurse's license to practice b) Criminal misdemeanor charges against the nurse c) Medical malpractice lawsuit against the nurse d) Employment release from the institution

ANS: A The state board of nursing is empowered to initiate disciplinary action against the nurse's license for professional misconduct. The board does not bring criminal charges or sentence the nurse to jail; that is the parameter of the state prosecutor and judge. A patient or the person harmed can bring medical malpractice lawsuits against the nurse.

The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound? a) Acute, full-thickness, open b) Chronic, partial-thickness, closed c) Acute, partial-thickness, closed d) Chronic, unstageable, open

ANS: A The wound is acute because it developed recently. The wound is full-thickness because it involves the dermis. The wound is open because it was bleeding, so the skin must be broken. The wound is contaminated because it is exposed to stool and appears to be infected.

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity? a) Young adult in traction who has a low-protein diet and dehydration b) Elderly patient diagnosed with well-controlled type 2 diabetes c) Middle-aged adult with metabolic syndrome taking antihypertensives d) Adolescent in bed with influenza having periods of high fever and diaphoresis

ANS: A The young adult patient in traction has multiple risk factors including immobility, dehydration, and inadequate protein intake. Healthy skin depends on adequate protein levels to maintain the skin, repair minor defects, and preserve intravascular volume. Therefore, this patient is at greatest risk for altered skin integrity. An elderly patient with well-controlled diabetes has only one risk factor, and therefore is not at highest risk among the group of patients in the scenario. The middle-aged adult with metabolic syndrome, which involves obesity, hyperlipidemia, and hypertension, has compromised health, although not necessarily compromised skin integrity—unless the patient were immobile, which he is not. Although fever and skin moisture can compromise skin integrity, the adolescent's condition is likely transient.

The emergency department nurse cares for a 17-year-old adolescent who is diagnosed with cervical cancer secondary to human papillomavirus. The patient declines treatment, saying, "I don't want my parents to know I have been sexually active, and if they find out about the cancer, they'll figure out the rest of it." The nurse explains the risk of death if the cancer is not treated, but the patient continues to refuse therapy. What conflicting principles is this nurse facing as the result of this patient's choices? a) Autonomy versus nonmaleficence b) Autonomy versus veracity c) Fidelity versus justice d) Veracity versus beneficence

ANS: A This nurse has to choose between maintaining the confidentiality (one aspect of autonomy) of the patient's health information versus the harm that will come to the patient if confidentiality is maintained (i.e., nonmaleficence). This nurse has to choose between maintaining the confidentiality of the patient's health information (an aspect of autonomy); however, veracity is the duty to tell the truth and is not a component of this scenario. Fidelity relates to fulfilling one's obligations and maintaining one's commitments; justice is the obligation to be fair. Neither fidelity nor justice is well described by this scenario. Again, veracity is the duty to tell the truth, and does not apply here; beneficence is the concept of doing good, which is not in conflict in this scenario because the nurse has done everything possible to help this patient make an informed choice.

The nurse receives a prescription to begin a morphine drip for a patient who is to be taken off the ventilator, and to increase the infusion rate as needed to maintain the patient's comfort. The nurse refuses to carry out the order because the morphine will depress respirations and the nurse believes this is equivalent to killing the patient. Which concept best describes what this nurse is demonstrating? a) Moral agency b) Morals c) Bioethics d) Clinical decision making

ANS: A This nurse is demonstrating moral agency because the nurse perceives the difference between right and wrong, understands the abstract moral principle of right to die versus euthanasia, applies moral principles to decision making, decides and chooses freely that this action is not right for the nurse to perform, and acts according to choice. Morals reflect what the nurse was taught about right and wrong, but that is only one component of what this nurse is demonstrating. Bioethics is the application of ethics to healthcare, but this is only one component of what this nurse is demonstrating. Although the nurse is making a clinical decision, this is only one component of what this nurse is demonstrating.

The nurse manager performs a risk-benefit analysis to determine the minimum number of staff the unit will need over the Christmas and New Year's holiday to allow as many nurses to take time off as possible while maintaining the safety of the patients. What ethical problem-solving approach is this nurse manager using? a) Utilitarianism b) Deontology c) Categorical imperative d) Feminist ethics

ANS: A Use of a risk-benefit analysis to determine every alternative action for its potential outcomes is utilitarianism. This nurse is using utilitarianism when balancing fairness to the staff with safety of the patients. Deontology is based on rules and principles using the language of rights and duties, or right and wrong, which does not apply to this manager's approach. The categorical imperative states one should act only if the action is based on a principle that is universal, which does not apply to this situation. Feminist ethics is based on the belief that traditional ethical models provide a mostly masculine perspective and devalue women, which does not apply to this nurse manager's problem.

Which of the following describes the difference between dehiscence and evisceration? a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. c) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

ANS: A With dehiscence, there is a separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site. Evisceration is an urgent complication usually requiring immediate surgical intervention.

What is the primary goal that the nurse should establish for a patient with an open wound? a) The wound will remain free of infection throughout the healing process. b) The client will complete antibiotic treatment as ordered. c) The wound will remain free of scar tissue at healing. d) The client will increase caloric intake throughout the healing process.

ANS: A Wounds healing by secondary intention are more prone to infection; therefore, the primary goal is to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs to increase caloric intake.

The nurse's obligations in ethical decisions include which of the following? Select all that apply. a) Be a patient advocate. b) Involve institutional ethics committees. c) Improve one's own ethical decision making. d) Respect patient confidentiality.

ANS: A, B, C, D The nurse's obligations in ethical decisions include being a patient advocate, using and participating in institutional ethics committees, and improving ethical decision making. Confidentiality is a basic patient right. The nurse's role is to uphold that right.

You are caring for a patient with renal failure. His morning laboratory results reveal an abnormal potassium level of 6.8. This value is higher than it was on the previous day, when the level was within normal limits. You page the patient's provider, but he does not return your call right away. You become busy with another patient and forget to notify the provider again and fail to mention the critical laboratory value to the oncoming nurse during shift report. Which of the following does this scenario illustrate? Select all that apply. a) Failure to implement a plan of care b) Failure to evaluate c) Malpractice d) Failure to assess and diagnose

ANS: A, B, D Failure to implement a plan of care and failure to evaluate are two of the most common causes of nursing malpractice claims. The scenario represents a failure to follow standards of care, failure to communicate, and failure to document, which are in the category of failure to implement a plan of care. It also represents a failure to assess and report a significant change in the patient's condition, which is part of the category of failure to evaluate. The nurse did assess the potassium level and recognize that it was too high. The scenario does not provide enough information to determine malpractice. To establish malpractice, the four elements of duty, breach of duty, causation, and injury/damages have to be established. There is no information provided regarding whether the patient suffered an injury as the result of the nurse's breach of duty.

Which of the following are examples of invasion of privacy by nurses? Select all that apply. a) Searching a patient's belongings without permission b) Reviewing the plan for patient care in the lunchroom c) Discussing healthcare issues for an unconscious patient with the person who holds his power of attorney d) Releasing patient health information to local newspaper reporters

ANS: A, B, D Invasion of privacy violates a person's right to be free from unwanted interference in her private affairs, such as occurs in discussing patient matters in a public setting; searching patients' private items without their permission; and releasing private information to the public. A durable power of attorney is a document empowering a person selected by the patient to make healthcare decisions in the event that the patient is unable to do so. It is permissible to discuss pertinent issues related to the welfare of the patient with the person holding a power of attorney.

The nurse arrives at work to find the unit will be short staffed for the shift because a nurse called in sick at the last minute, leaving no time to find a replacement. What factors contribute to the dilemma faced by the nurse working this shift? Select all that apply. a) The nurse's multiple obligations and relationships b) Value conflicts and lack of clarity within the profession c) Autonomy versus escaping hard choices d) Higher pay versus cost effectiveness e) Caring versus the decreased time to spend with patients

ANS: A, B, E The nurse's multiple obligations influence this dilemma because the nurse may want to refuse to work short staffed because of safety issues, but wants to provide care for patients, and does not want to be fired for refusing to work under these conditions. The nurse's dilemma is partially owing to lack of clarity within the profession. Although the profession discusses the possibility of legal nurse-to-patient ratios, there is a lack of clarity about the best way to avoid short staffing. As well, there is a professional duty not to abandon patients. The nurse's dilemma is also focused on the realization that there will be inadequate time to care for patients adequately, or at least not as well as the nurse believes is her duty. Higher pay and cost-effectiveness are not about autonomy because the nurse is not giving up her autonomy by escaping hard choices and letting the provider choose her course of action. This shortage was not caused by reduction in staff to save money, but instead by a nurse calling in too late to provide adequate time to find a replacement.

What are the elements that the plaintiff must establish in a malpractice lawsuit? Select all that apply. a) Duty b) Breach of duty c) Intent to harm d) Assault e) Causation f) Injury

ANS: A, B, E, F For a malpractice suit to occur, duty, breach of duty, causation, and injury must be proved. Intent to harm and assault are types of crimes that are not part of the elements of malpractice suits.

What do negligence and malpractice have in common? Select all that apply. a) Negligence and malpractice are unintentional torts. b) Negligence and malpractice are felonies. c) Malpractice is the professional form of negligence. d) Negligence and malpractice involve the intent to do harm to a patient.

ANS: A, C Negligence and malpractice are unintentional torts—nurses can be negligent without intending to do harm. Negligence is simply the failure to use ordinary or reasonable care as dictated by the standards of practice and/or by what a reasonable and prudent nurse would do in the same or similar circumstances. Intent is not an element of negligence. When a nurse or other licensed professional healthcare provider is negligent and fails to exercise ordinary care, it is called malpractice. Malpractice is the professional form of negligence.

Which of the following is an example of whistleblowing? Select all that apply. a) Reporting fraudulent billing practices b) Reporting patient's health status against the patient's wishes c) Reporting unsafe work practices d) Reporting a coworker for working under the influence of drugs

ANS: A, C, D Reporting a patient's health status against the patient's wishes is a breach of patient confidentiality. Whistleblowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. Fraudulent billing practices are illegal and unethical; unsafe work practices are unethical and illegal; and a coworker under the influence of drugs is a risk to patients, as well as acting in an illegal and unethical manner.

The nurse is caring for a patient who experienced a stroke leaving the left side of the body paralyzed. The patient says, "I can still bathe myself," but the nurse performs the bath to make certain the patient gets clean. What ethical principles is the nurse violating with this behavior? Select all that apply. a) Beneficence b) Fidelity c) Autonomy d) Veracity e) Nonmaleficence

ANS: A, C, E Beneficence is doing good, and performing care for the patient rather than encouraging the patient to do as much for himself as possible is not doing the patient any good. To do good for this patient, the nurse should encourage the patient to perform as much of the bath as possible so he will regain his strength. The nurse is limiting the patient's autonomy by not encouraging the patient to do as much self-care as possible and not respecting the patient's desire to try bathing by himself. Nonmaleficence is doing no harm and the nurse is harming this patient by encouraging dependence instead of autonomy. Fidelity is being loyal; this principle is not relevant to the scenario. Veracity means the nurse should be honest; this principle is not relevant to the scenario.

Of the following, which is the best choice for performing wound irrigation? a) Water jet irrigation b) 35-mL syringe with a 19-gauge angiocatheter c) 5-mL syringe with a 23-gauge needle d) Bulb syringe

ANS: B A 35-mL syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and 5-mL syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. A bulb syringe is not an appropriate choice because there is an increased risk of aspirating drainage from the wound.

What is a common characteristic of aging skin? a) Increased permeability to moisture b) Diminished sweat gland activity c) Reduced oxygen-free radicals d) Overproduction of elastin

ANS: B Aging skin tends to be drier. Sweat gland activity is diminished. The skin's connective tissue, collagen, and elastin are reduced, which means the skin loses firmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and environmental sources. An infant's skin is thinner and more permeable to moisture in the environment.

A 4-year-old child is brought to the emergency department by his mother. He has a large bruise on his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four correct items should the nurse do first? a) Notify the nursing supervisor of the suspected physical abuse. b) Complete a physical assessment of the child. c) Obtain an order for pain medication. d) Notify Child Protective Services of the suspected abuse.

ANS: B Although the nurse must report to designated authorities (Child Protective Services) suspected physical abuse, the primary responsibility of the nurse in this situation is to evaluate the patient's physical condition and extent of his injuries for appropriate medical treatment to be provided. Pain medication should not be administered prior to a thorough physical assessment. The nurse should always notify the nursing supervisor if any outside agencies may need to be contacted.

A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? a) Steri-Strips b) Abdominal binder c) T-binder d) Paper tape

ANS: B An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would not be needed for an approximated incision that has intact staples or sutures.

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives: a) Can cause cellular toxicity b) Increase the risk of ischemia c) Delay wound healing d) Predispose to hematoma formation

ANS: B Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury.

The Code of Ethics for Nurses: a) Is legally binding b) Is not legally binding c) Is legally binding in some circumstances d) Cannot be used in legal cases

ANS: B Codes of ethics are open to public scrutiny. The ethical aspects of nursing work, just like the technical aspects, are subject to review by professional groups and licensure boards, which may use sanctions to punish code violations. The Code of Ethics for Nurses establishes standards of practice for nurses. Although nursing codes are not legally binding, they are often used in legal cases involving nurses (e.g., malpractice) to identify deviations from professional standards of practice.

The nurse enters a patient's room with a portable computer station to assess the patient. The nurse does not log out while assisting a patient to the bathroom. A visitor reads the patient's chart and begins to question the nurse about the patient information. This is an example of: a) Failure to educate the patient b) Failure to maintain patient confidentiality c) Negligence regarding the patient's care d) Failure to educate the visitor

ANS: B Even though it was an inadvertent act in this situation, failure to maintain patient confidentiality and privacy are applicable to patient records. By not closing the patient electronic medical record, the nurse made it available to someone not directly involved with the patient's care. Family and friends do not have the right to have access to the patient's chart by virtue of their relationship to the patient. Educating the patient or visitor or the lack to do so have nothing to do with this item. There was no negligence in care to the patient by the nurse in this situation.

In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient? a) The patient is confused and cannot understand or sign the consent form. b) The patient is brought to the emergency department in cardiac arrest; no family is present. c) The surgeon requests that the patient be sent to the surgical suite before the nurse gets the consent form signed. d) An unconscious patient is admitted to the nurse's unit; he is alone.

ANS: B Informed consent is the necessary authorization by the patient for any and all types of care and must be written and signed by the patient or the person legally responsible for the patient for hospital admission and for invasive or specialized treatments or diagnostic procedures. Written consent is not necessary in an emergency if experts agree that there was an immediate threat to life or health. It is the physician responsible for the care of the patient who has the duty to obtain informed consent from the patient.

Identify the third step in the MORAL decision-making model. a) Reassess the dilemma. b) Resolve the dilemma. c) Review the problem. d) Recall the history of the problem.

ANS: B MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate.

The nurse in the emergency department admits a patient with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing? a) Serous b) Sanguineous c) Purosanguineous d) Purulent

ANS: B Sanguinous drainage contains blood, which would be expected from a wound with active bleeding. Serous drainage is clear, faintly yellow drainage. Serous drainage occurs when there is inflammation, such as with a burn injury. Purosanginous fluid contains pus, which occurs with infection. This patient has a wound from an acute injury. Although infection risk is high with gunshot wounds, infection generally takes 2 or more days to occur. Purulent drainage indicates infection. This wound is too recent to demonstrate infection.

A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: a) Primary intention healing b) Secondary intention healing c) Tertiary intention healing d) Approximation healing

ANS: B Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges.

While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a) Sanguineous b) Serosanguineous c) Serous d) Purosanguineous

ANS: B Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged.

The nurse believes that abortion is wrong, but applies the MORAL model and decides that caring for patients following an abortion is her ethical duty. When evaluating the effectiveness of the nurse's decision process, what finding would indicate the nurse made the best choice? a) The patient is discharged without experiencing complications from the procedure. b) The nurse believes quality care was delivered and feels satisfied with the decision. c) The nurse manager commends the nurse for providing excellent patient care. d) The patient thanks the nurse for being supportive during a difficult time.

ANS: B The fact that the nurse believes the right thing was done and has a sense of satisfaction with the decision is the important focus of an evaluation of a decision process. A positive patient outcome (i.e., discharge without complications) reflects good nursing care but is not a good criterion for evaluating an ethical decision process. No matter how carefully a process is applied, and no matter how well a moral decision is justified, you can never be certain of obtaining a good outcome for the patient because there are many variables other than moral variables that affect an outcome. The same is true for the quality of the nurse's patient care. The fact that the nurse thanks the nurse has no bearing on how well the decision process worked.

The patient has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound? a) Pressure ulcer b) Venous stasis ulcer c) Diabetic foot ulcer d) Arterial ulcer

ANS: B The location of the ulcers and the history of past deep vein thrombosis would make venous stasis ulcers the most likely classification for these wounds. They occur usually between the inside ankle and the knee, not necessarily over a bony prominence, and are typically red in color, shiny, and taut, and may even feel warm or hot. Fluid drainage can be significant. A pressure ulcer is unlikely to develop on the medial side of the calf because it is neither a bony area nor one that is likely to be an area where there is pressure. There is no indication that this patient is diabetic and the wound is not on the foot. An arterial (ischemic) ulcer tends to be dry and pale, with little drainage. Arterial ulcers are usually very painful, especially at night.

A nurse is providing care to a patient who is a Jehovah's Witness. Against the patient's wishes, the physician ordered the nurse to give the patient two units of packed red blood cells. The nurse knows that the blood will save the patient's life, but also that it is against the patient's wishes; she is unsure what is the right thing for her to do. The nurse is experiencing a(n): a) Reflection encounter b) Ethical dilemma c) Moral outrage d) Moral distress

ANS: B The nurse is experiencing an ethical dilemma based on the conflict between the ethical principles of beneficence and autonomy. The nurse has not yet made a decision. This is not a situation of moral distress, in which the nurse would have made an acceptable moral decision, but was unable to implement it because of external constraints. The nurse does not perceive that others are acting immorally; thus, this is not moral outrage.

The nurse witnesses the patient's signature on a consent form to participate in her physician's research study. After the physician leaves the room, the patient tells the nurse she really doesn't want to participate but didn't have the heart to turn down the request because of fear that the physician would be upset. What should the nurse do to advocate for this patient? a) Tell the patient the physician will not be upset. b) Tell the physician why the patient agreed to participate. c) Explain the importance of the research study to the patient. d) Ask the patient what she would like you to do.

ANS: B The nurse should inform the physician of the patient's feelings and encourage the physician to talk with the patient to give her permission to change her mind. While the nurse can say the physician will not be upset, and it is likely to be true, it will not change how the patient feels nor provide her the opportunity to change her mind. Explaining the importance of the study would probably make the patient feel even more obligated to participate. The patient is likely to tell the nurse not to do anything, so the patient's needs would still go unmet.

An 87-year-old patient has just been diagnosed with cancer. Her durable power of attorney names her son as her surrogate decision maker. He arrives at the patient's bedside to discuss treatment options with her. The patient is alert and oriented. Her son tells you that he does not want her to receive any treatment (chemotherapy) because of the side effects and her age. The patient tells you that she wants to try the treatment. Which decision should be followed by the nurse? a) The patient's son's b) The patient's c) Both—initially the patient's; then the son's when the medication's side effects become severe d) Neither; this is a legal decision and should be made by a court of law

ANS: B The patient is alert and oriented and can make her own healthcare decisions. The son only has the authority to make healthcare decisions once his mother becomes incompetent and unable to process information to make decisions. This is not an issue for the court. The patient will decide if and when to discontinue treatment.

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to resolution of the conflict. The nurse asks the hospital chaplain to come and help the family and the team understand each other's opposing views. Which step of the MORAL model does this illustrate? a) M—Massage the dilemma b) O—Outline the options c) R—Resolve the dilemma d) L—Look back and evaluate

ANS: B This illustrates the Outlining the options step. In Massaging the dilemma, the team would already have identified and defined the issues in the dilemma, and considered the values and options of all the major players. At the Outlining the options step, someone should delineate all of the options to all parties, including those that are less realistic and conflicting. In that step, someone often asks a member of the ethics committee or the hospital chaplain to help the parties understand the opposing viewpoints. Resolving the dilemma is the step in which all the options are reviewed and basic ethical principles and frameworks are applied to arrive at a decision. Looking back to evaluate is done after a decision has been made and acted on. At that time, the entire process, including the consequences, are evaluated to determine how well they worked.

A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? a) Risk for Infection related to subcutaneous injuries b) Risk for Impaired Skin Integrity related to immobility c) Impaired Tissue Integrity related to ventilator dependency d) Impaired Skin Integrity related to ventilator dependency

ANS: B This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.

Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient's arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws? a) Good Samaritan Law b) Mandatory Reporting Law c) Nurse Practice Act d) Nursing Standards of Practice

ANS: B Under state mandatory reporting laws, nurses must report to designated authorities (e.g., Adult Protective Services) suspected physical, sexual, emotional, or verbal abuse or neglect by healthcare workers or family members. In general, nurses who fail to report suspected abuse or neglect may be held criminally or civilly liable.

A surgeon refused a patient's request to restart a patient's total parenteral nutrition (giving nutrition through the intravenous route) because he believed that a greater good would be achieved by not using medical resources to prolong the life of a terminally ill patient when the resources could be used for other patients. Which ethical theory best explains the surgeon's rationale? a) Ethics of care b) Utilitarianism c) Deontology d) Categorical imperative

ANS: B Utilitarianism is a consequentialist theory that takes the position that the value of an action is determined by its usefulness. The surgeon believes that providing TPN to a terminally ill patient is useless, because it will not prevent her death, and furthermore that it does not achieve the "greater good." Other patients with a better prognosis would benefit from the TPN. An ethics of care is a nursing philosophy that directs attention to the specific situations of individual patients viewed within the context of their life narrative. Deontology considers an action to be right or wrong independent of its consequences. The surgeon is guided by the usefulness of the act, not one of duty. A categorical imperative is a principle, established by Immanuel Kant, that states that one should act only if the action is based on a principle that is universal.

The nurse is caring for a patient diagnosed with a brain tumor who is about to undergo surgery to have the tumor removed. Before the surgery, the patient signs a document giving instructions to his family regarding the level and extent of life-prolonging treatments he desires. Which of the choices below describe this legal directive? Select all that apply. a) The document is a durable power of attorney for healthcare. b) The document is a living will. c) The family can make decisions that are consistent with the document if the patient is incompetent. d) The family is able to decide to prolong the patient's life, even if he does not want it. e) The family has guidance on the treatments the patient wants.

ANS: B, C, E This is an example of a living will that directs the family members to have care given to the patient based on what the patient wants if the patient is unable to make these decisions. With this document, the family cannot choose to do something the patient did not request. As described in the item, this is not a power of attorney, giving someone else the right to make healthcare decisions for the patient should he become incapable of making those decisions.

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. a) Granulation b) Hemostasis c) Epithelialization d) Inflammation

ANS: B, D During the inflammatory phase of wound healing, hemostasis and inflammation occur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site.

Under the American Nurses Association (ANA) Code of Ethics, the nurse has the professional responsibility to uphold ethical behavior. Choose the statements below that are accurate about the Code of Ethics. Select all that apply. a) ANA Code of Ethics is a law. b) Nurse actions are to be at the level expected by the profession. c) Nurses are not held accountable for their actions. d) Nurses are professionally bound to give correct information to the patient. e) Nurses do not need to collaborate to meet a patient's healthcare needs. f) ANA Code of Ethics will protect the nurse even if the law is broken.

ANS: B, D The ANA Code of Ethics is not a law, but rather standards of professional responsibilities of the nurse using behavior that is ethical and expected by or acceptable to the profession. Under the Code of Ethics, nurses are bound to give correct information to patients. Collaboration is not forbidden in the Code. The Code of Ethics is not a law and won't protect the nurse who is in violation of them.

A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? a) Dry gauze dressing changed twice daily b) Nonadherent dressing with daily wound care c) Hydrocolloid dressing changed as needed d) Wet-to-dry dressings changed three times a day

ANS: C A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic debridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical debridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well.

What intervention would be most appropriate for a wound with a beefy red wound bed? a) Mechanical debridement b) Autolytic debridement c) Dressing to keep the wound moist and clean d) Removal of devitalized tissue and a sterile dressing

ANS: C A red wound indicates active healing, and the best treatment is gentle cleansing and a dressing that will ensure a clean, moist wound environment. Debridement is not necessary in this situation because there is no devitalized tissue present.

The nurse overhears a coworker say, "How can an overweight nurse teach proper nutrition? That nurse should practice what is taught." Which concept best describes what the coworker is expressing? a) Morals b) Ethics c) Values d) Compromise

ANS: C A value is a belief about the worth of something. This coworker is diminishing the worth of the overweight nurse through the statement made, which goes against nursing values of compassion and human dignity. Morals are something we learn that help us differentiate good from bad, right from wrong. Ethics is the study of a system of moral principles and standards; therefore, this coworker is not expressing ethics. A compromise is a solution in which parties with opposing positions all settle on a solution to a problem that is somewhere between what each party would ideally like to have. This nurse is simply stating her own position

While applying a wet-to-dry dressing, how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a: a) Method of submerging the wound in water, allowing it to soak before drying the wound bed b) Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed c) Means of debriding the wound but also removing granulation tissue from the wound d) Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue

ANS: C A wet-to-dry dressing uses coarse gauze moistened with normal saline that is packed into the wound, allowed to dry, and then removed, perhaps several times a day. This form of nonselective debridement removes not only debris, but also granulation tissue from the wound. It is also quite painful. Hydrotherapy or whirlpool treatments are nonselective debridement wherein the wound is submerged in a whirlpool containing tepid water for a prescribed amount of time (usually 5 to 15 minutes). This form of debridement is reserved for wounds with a large amount of nonviable tissue, such as burns. Enzymatic debridement uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound. To use an enzymatic product, clean the wound with normal saline, apply a thin layer of the cream, and cover with a moisture-retaining dressing. Autolysis breaks down necrotic tissue by using an occlusive, moisture-retaining dressing (e.g., transparent dressing) and the body's own enzymes and defense mechanisms. This process takes more time than the other techniques, but it is better tolerated.

A patient who is being discharged asks the nurse, "Can I take you out for dinner to show my appreciation for all that you have done for me? I really like you." The nurse's best response is which of the following? a) "Yes, that would be nice. It is really great to be appreciated." b) "No, and please do not ask again. You should have been told that already." c) "Thank you; however, I have to refuse, even though the thought is appreciated." d) "We will have to wait 3 days after you have been discharged to have a relationship."

ANS: C Accepting gifts from patients is a breach of professional boundaries: social contact. Nurses cannot accept gifts from patients in the form of dinners, money, social contact, and the like. The nurse should not enter into a relationship based on the patient's attempt to compensate her for performing her role responsibilities. Waiting 3 days would not change that. Telling the patient not to ask again, and that she should already know that, borders on rudeness. Although it reflects the understanding about gifts and professional boundaries, it is not an empathetic response and would not help build a trusting relationship.

A registered nurse forgot to put the siderails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurse's situation is that her insurance policy will do which of the following? a) Not cover her b) Pay $4 million c) Pay $2 million d) Pay 75% of the $2 million

ANS: C An occurrence policy will cover those claims that occurred during the time the policy was in effect. The policy will pay up to $3 million per claim; because the amount awarded does not exceed this, the nurse is covered.

When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? a) The patient will need to take antibiotics until the wound is completely healed. b) Because the patient's wound was left open, the wound will likely become infected. c) The patient will have more scar tissue formation than there would be for a wound closed at surgery. d) The patient should expect to remain hospitalized until complete wound healing occurs.

ANS: C Because the wound edges are not approximated, more scar tissue will form. Although open wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting.

You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, "I'm leaving this hospital. Remove my IV and surgical drains or I will do it myself." To keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following? a) Assault and battery b) Felony c) False imprisonment d) Quasi-intentional tort

ANS: C False imprisonment involves an intentional or willful detention of a patient without consent or authority to do so. Restraining a patient without consent is another form of civil false imprisonment. Competent patients have a right to leave an institution, even if it is harmful to their health. Whenever possible, have the person sign a form stating that he is aware that he is leaving against medical advice.

The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following? a) Malpractice b) Incompetence c) Negligence d) Abandonment

ANS: C Negligence is the failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent (careful) manner. It is negligent to assign a nurse to care for a patient without verifying the nurse has training, experience, and clinical competence in caring for such patients.

The charge nurse uses a whiteboard located at the nurse's station to write the nurses' patient assignments and the patients' diagnoses. This is a violation of which of the following? a) Americans with Disabilities Act (ADA) b) Patient Self-Determination Act (PSDA) c) Health Insurance Portability and Accountability Act (HIPAA) d) Health Emergency Medical Treatment and Active Labor Act (EMTALA)

ANS: C The Health Insurance Portability and Accountability Act (HIPAA) provides comprehensive protection for the privacy of protected health information (confidentiality of patient records). Writing the nurses' assignments with the corresponding patients and their diagnoses in a location where others may view it is a violation of HIPAA. Assignments should be kept in the nurses' conference room or a location that is not accessible to patients, their family members, or visitors.

On a patient's admission to the hospital, a nurse asks the patient whether he has a living will or durable power of attorney for healthcare. He states he does and provides a copy for the chart. The basis for the nurse's inquiry is which of the following? a) Code of Ethics for Nurses b) Patient Care Partnership c) Patient Self-Determination Act (PSDA) d) Health Insurance Portability and Accountability Act (HIPAA)

ANS: C The PSDA require healthcare facilities to provide patients with information on advance directives on admission. HIPAA protects a patient's medical information. The Code of Ethics for Nurses provides guidelines to nurses on acceptable and expected professional behaviors and practices. The Patient Care Partnership provides patients with their rights and what to expect during hospitalization.

The nurse is a member of the ethics committee. An alert, oriented, and competent 87-year-old man has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and requests the ethics committee to intervene on their behalf. The ethics committee would most likely use which model in this patient's case? a) Social justice b) Patient benefit c) Autonomy d) DNAR (AND) determination

ANS: C The autonomy model is useful when the patient is competent to decide. This model emphasizes patient autonomy and choice as the highest values. The patient benefit model assists in decision making for the incompetent patient by using substituted judgment. The social justice model focuses more on broad social issues involving the entire institution rather than on a single patient issue. There is no DNAR (AND) determination model.

Which client does the nurse recognize as being at greatest risk for pressure ulcers? a) Infant with skin excoriations in the diaper region b) Young adult with diabetes in skeletal traction c) Middle-aged adult with quadriplegia d) Older adult requiring use of assistive device for ambulation

ANS: C The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal.

For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? a) Client will maintain intact skin throughout hospitalization. b) Client will limit pressure to wound site throughout treatment course. c) Wound will close with no evidence of infection within 6 weeks. d) Wound will improve prior to discharge as evidenced by a decrease in drainage.

ANS: C The goal for any wound is for healing to take place with no complications (such as infection). Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer.

The nurse observes a new graduate nurse preparing to place an IV catheter in the patient's arm. The new graduate tells the patient, "You won't feel a thing" before inserting the needle under the skin. What ethical principle did the new graduate violate? a) Beneficence b) Nonmaleficence c) Veracity d) Confidentiality

ANS: C The graduate nurse was not honest with the patient, so the ethical principle of veracity was violated. The scenario does not describe the nurse performing the procedure incorrectly, so there is no reason to think that the graduate did not provide good care. There is no indication the patient was harmed, so the nurse did not violate nonmaleficence. There is no indication the new graduate shared any private, sensitive information about the patient with others; therefore, confidentiality was maintained.

The nurse admits an older adult patient to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment? a) Apply transparent film dressings to buttocks. b) Reassess using the Braden Q scale. c) Conduct another assessment in 3 days. d) Massage areas over the bony prominences.

ANS: C The initial Braden scale assessment should be repeated in 48 to 72 hours to establish an accurate baseline. Application of barrier products, such as transparent film dressing, prior to a thorough and accurate assessment of need is premature, and possibly unneeded. The Braden Q scale is used to assess pressure ulcer risk in children. Massaging the area over bony prominences could irritate the skin and lead to injury.

A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? a) Transparent film dressing b) Sheet hydrogel c) Frequent turn schedule d) Enzymatic debridement

ANS: C The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic debridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure.

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: a) The ulcer is completely healed with minimal scarring b) The patient reports no pain at the site c) A minimal amount of drainage is noted d) The wound bed contains 100% granulated tissue

ANS: D A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar.

1. What is the function of the stratum corneum? a) Provides insulation for temperature regulation b) Provides strength and elasticity to the skin c) Protects the body against the entry of pathogens d) Continually produces new skin cells

ANS: C The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface.

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. The healthcare team does not comply with the family's wishes, and after several days the family takes the matter to court. The court sides with the family and orders the healthcare team to remove the DNAR (AND) prescription. This is an example of which of the following? a) An integrity-producing (good) compromise b) An ethically sound compromise c) Settlement of an issue by force d) An effort to keep peace on the unit

ANS: C This is clearly an example of settling an issue by force, bringing in a more powerful entity (the court) to force the healthcare team to do what the family wants. It is not a compromise—of any sort—because neither party backed away from its original position, and the action that was taken was not agreed on by both parties. This was not an effort to keep peace. The family's effort was to settle the disagreement in their favor. If the healthcare team's goal had been to keep peace on the unit, they would have acceded to the family's wishes without the need for a court order.

The nurse faces a true ethical dilemma and uses several strategies for resolving the issue. What is the likely outcome? a) A satisfying solution will be found if the nurse logically applies more than one strategy for decision making. b) If the nurse involves other members of the healthcare team in the decision-making process, a compromise will be reached that satisfies everyone. c) The nurse will nevertheless probably not be comfortable with any course of action, regardless of the strategy, model, or type of reasoning used. d) A decision can be reached that is comfortable for the nurse if the nurse applies a decision model to the dilemma.

ANS: C True ethical dilemmas involve deciding between the better of two negative outcomes, so the nurse will probably not be comfortable with any course of action, regardless of the strategy, number of strategies, model, or type of reasoning used. Because of the nature of a dilemma, even with the involvement of other team members it is unlikely the decision will be fully satisfying to any one participant. Ethical decision-making models will help the nurse carefully consider several perspectives, guide reasoning, and explain reasons for final action; however, true ethical dilemmas require deciding between the lesser of two evils, so any conclusion is likely to be unsatisfying in some ways.

A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor. The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, "We don't have any money or insurance, but this hospital is closer than the public hospital, and she needs help now." What is the first step that the ED staff should take? a) Arrange for an ambulance to transport her to the nearest public hospital. b) Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. c) Examine her to determine whether her condition is stable or whether she requires immediate medical attention. d) Inform her mother that she will need to transport her daughter to the nearest public hospital.

ANS: C When a client comes to the ED requesting examination or treatment for an emergency medical condition (including labor), the hospital must provide stabilizing treatment; the client cannot be transferred until she is stable.

While you are admitting an adult patient, he asks you whether he should create an advance directive. To provide him adequate information to make an informed decision, you should tell the patient which of the following? Select all that apply. a) If he is unable to communicate, his family may make changes to his advance directive. b) Once he signs an advance directive, no further care will be provided to him. c) He may change his advance directive by telling his physician or by making changes in writing. d) An advance directive will ensure he gets as much or as little care as he wishes.

ANS: C, D Advance directives include living wills and durable powers of attorney. A living will establishes the patient's wishes regarding future healthcare should he become unable to give instructions. A patient may specify actions in a living will that are not supported by family members, such as a desire for a "do not resuscitate" order, or for as much or as little care as he wishes. A person may change or revoke an advance directive at any time. Changes and written revocation should be signed and dated and shared with the patient's physician. Even without an official written change, orally expressed direction to the physician generally has priority over any statement made in an advance directive as long as the patient is able to decide for himself and can communicate his wishes.

What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply. a) Pressure Ulcer Healing Chart b) PUSH tool c) Braden scale d) Norton scale

ANS: C, D The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The Norton scale is another tool used to assess the risk for pressure ulcers based on the patient's physical condition, mental state, activity, mobility, and incontinence. These are the two most used risk assessment tools in the United States. Both of these tools are used to identify persons at high risk of pressure ulcer development. The PUSH tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to monitor the progression of a pressure ulcer.

The parents of a 12-year-old boy refuse chemotherapy to treat the child's leukemia, saying they will not ruin what is left of his life with drugs that will make him feel sicker. Which solution to this ethical dilemma would demonstrate compromise, maintaining the integrity of all involved? a) Agreeing to allow the child to avoid chemotherapy b) Explaining to the parents that without chemotherapy the child will die. c) Obtaining a court order to require the parents to allow chemotherapy. d) Agreeing to administer the chemotherapy agent with the fewest side effects.

ANS: D Administering the chemotherapy agent with the fewest side effects demonstrates a compromise because the child receives treatment, but the parents' concerns about side effects are also considered. Allowing the child to avoid chemotherapy yields to the parents' concerns, but not the concerns of the healthcare team to do no harm to the child. Frightening the parents into agreeing with the healthcare team is coercion; a good compromise must be entered into freely. A court order is settling things by force and the parents lose their argument; a compromise cannot be obtained by force.

The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply? a) Alginate b) Antimicrobial petroleum gauze c) Foam dressing d) Antimicrobial collagen dressings

ANS: D An antimicrobial collagen dressing promotes wound healing, is absorbent, and is treated with an antimicrobial to promote infection resolution. Although alginate dressings will absorb the drainage, they do not treat the infection. Petroleum gauze is not absorbent and would not be the best choice for a draining wound. Foam dressings are highly absorbent, but they will not treat the infected wound.

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? a) Stage II pressure ulcer b) Stage III pressure ulcer c) Stage IV pressure ulcer d) Unstageable pressure ulcer

ANS: D An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

Confidentiality will be maintained by a nurse who believes in and values the ethical principle of: a) Fidelity b) Veracity c) Beneficence d) Autonomy

ANS: D Autonomy refers to a person's right to choose and his ability to act on that choice. An autonomous person has control over the collection, use, and access of his personal information. This information should not be shared without the patient's consent. Veracity means to tell the truth. Beneficence is the duty to do or promote good. Fidelity is the obligation to keep promises.

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? a) Draw a circle around the area of drainage on a dressing. b) Classify drainage as less or more than the previous drainage. c) Weigh the patient at the same time each day on the same scale. d) Weigh dressings before they are applied and after they are removed.

ANS: D By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound but it does not provide information on how much fluid is draining.

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client a) Begins an aggressive exercise program b) Follows a diet plan of 1,200 calories per day c) Is fitted for deep-depth diabetic footwear d) Remains free of foot wounds

ANS: D Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities. Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet. The nurse will know this plan of care is effective when the client's feet remain free of wounds. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet. Similarly, a 1,200-calorie diet would be inadequate for most clients. Being fitted for diabetic footwear is an intervention rather than a goal.

The nurse believes that abortion is murder of the unborn child. While at work, the nurse is assigned a woman with septicemia following an abortion. Which concept most specifically requires the nurse to provide high-quality care for this patient? a) Ethics b) Morals c) Bioethics d) Nursing ethics

ANS: D Ethics is a system of moral principles and standards that helps to decide conduct and actions, so although this applies to the situation, it is a more general guide and is not specific to this situation; there is a better answer choice. Morals are taught to us as children to guide behavior, such as learning that abortion is murder. However, this does not apply specifically to the nurse's care for this woman. Bioethics refers to the application of ethical principles to healthcare, but is not exactly the term we should use in this case - the nurse can provide high-quality care to someone who has a different set of morals from her own. Nursing ethics are a specific subset of bioethics that apply only to nurses, and is the specific concept upon which the nurse's behavior is based.

A patient has asked the nurse to explain her laboratory results. The nurse informs the patient that he must first assist another patient to the bathroom and then he will return to explain the results. After assisting the other patient to the bathroom, the nurse returns to explain the results to the patient. What ethical principle has the nurse displayed? a) Nonmaleficence b) Autonomy c) Beneficence d) Fidelity

ANS: D Fidelity is the obligation to keep promises. Autonomy refers to a person's right to choose and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? a) Is actively bleeding b) Has swollen, tender insect bite c) Has just sprained her ankle d) Has lower back pain

ANS: D Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the healing process. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and leaky capillaries, all of which would be harmful to the patient who is actively bleeding. It can lead to a drop in blood pressure. Heat should not be applied to a site with inflammation (insect bite or acute joint injury with swelling) because it can increase edema to the site. A good application for heat therapy is to promote comfort and relaxation to the patient experiencing back pain.

Nursing codes of ethics support which of the following? a) Patients can receive emergency treatment regardless of their ability to pay. b) Nurses will educate patients about advance directives. c) Nurses with HIV must disclose their condition to their employer. d) Patients have the right to dignity, privacy, and safety.

ANS: D In the Patient Bill of Rights, patients have the right to dignity, privacy, and safety. Although they are not laws, nursing codes of ethics specify ethical duties of the nurse to the patient as related to corresponding patient rights. Although patients do have a right to receive emergency medical care regardless of their ability to pay, this is not part of the nursing code of ethics. Likewise, a nurse's role is to educate patients about advance directives; this is a goal supported by nursing organizations but is not part of the code of ethics.

The nurse cares for a patient who is diagnosed with a sexually transmitted infection (STI). The patient is upset and asks the nurse not to share this information with anyone. The nurse explains to the patient that this must be reported to the local Health department based on which regulation? a) Americans with Disabilities Act (ADA) b) Whistleblower's law c) Good Samaritan Law d) Mandatory reporting

ANS: D Mandatory reporting is state law that requires health practitioners to report STIs to reduce the incidences of more people being infected/reinfected. The Good Samaritan Law is designed to protect from liability those people who assist in an emergency situation outside of the workplace. The Americans with Disabilities Act (ADA) protects those with disabilities from discrimination. Whistleblower's law protects those who report wrongdoing by corporations or others that have the potential to harm others.

A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patient's left heel. What is the initial treatment for this pressure ulcer? a) Antibiotic treatment for 2 weeks b) Normal saline irrigation of the ulcer daily c) Debridement to the left heel d) Elevation of the left heel off the bed

ANS: D Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patient's left heel off the bed would relieve pressure to this area. Antibiotics treat infection; a stage I pressure injury is not infected. Skin of a stage I pressure wound is intact but has nonblanchable redness; therefore, irrigation is not indicated for stage I pressure wounds. The area may be painful, firm, soft, or warmer or cooler as compared with adjacent tissue, but is not deep enough for debridement.

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? a) Stage I pressure ulcer, healing b) Stage II pressure ulcer, healing c) Stage III pressure ulcer, healing d) Stage IV pressure ulcer, healing

ANS: D Reverse staging is not done because, as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? a) Primary intention b) Regenerative healing c) Secondary intention d) Tertiary intention

ANS: D Tertiary intention is used when a wound is clean-contaminated or "dirty" (potentially infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed.

The American Nurses Association (ANA) believes nurses should not participate in active euthanasia (and assisted suicide) because such acts violate ____. a) the Patient Self-Determination Act b) civil laws c) the Good Samaritan laws d) the Code of Ethics for Nurse

ANS: D The ANA defines assisted suicide, a form of active euthanasia, as providing a patient the means to end his life, with full knowledge of the patient's intentions to do so. The ANA believes that participation in active euthanasia violates the Code of Ethics for Nurses and the ethical traditions of the profession.

An adult patient is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The patient has no problem with rubbing, friction, or shear. What is the Braden score for this patient? a) 0 b) 15 c) 20 d) 23

ANS: D The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the patient's risk: the lower the score, the more likely the patient will develop a pressure ulcer. The patient receives four points for sensory perception, moisture, activity, mobility, and nutrition and three points for friction and shear, making a total of 23 points, which is a perfect score.

What is the primary difference between acute and chronic wounds? Chronic wounds: a) Are full-thickness wounds, but acute wounds are superficial b) Result from pressure, but acute wounds result from surgery c) Are usually infected, whereas acute wounds are contaminated d) Exceed the typical healing time, but acute wounds heal readily

ANS: D The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds.

Which statement describes the primary purpose of an incident report? a) This report is used by nurse managers to discipline the nurse for her errors. b) It is imperative that this report be kept in the patient's medical record in case of a lawsuit. c) A copy should be provided to the patient to promote open communication. d) This report is used by risk management to prevent the incident from reoccurring.

ANS: D The main function of an incident report is to prevent the incident from happening again. The report allows the nurse manager and risk management to evaluate the context in which the incident occurred and to identify appropriate strategies to prevent a reoccurrence. Although incident reports have been used to discipline nurses, this is not the current trend and is not their purpose. These reports are not a part of the patient record and therefore are not part of accurate patient charting. A copy should not be shared with the patient.

The patient is struggling with a decision whether or not to receive experimental treatment. What is the nurse's role when caring for this patient? a) Provide recommendations for decision making. b) Teach the patient how to apply logic to the situation. c) Advocate for the patient with the primary healthcare provider. d) Listen to the patient's thoughts, ask questions, and provide support.

ANS: D The nurse's role while the patient is making a decision is to support the patient, listen to his thoughts, ask questions to help the patient think things through, and provide unbiased information. The nurse should not lead the patient to what the nurse thinks is best, but allow the patient to make his own decision (autonomy). Although the nurse may help the patient think through the decision, the nurse would not teach the patient how to make a decision because this could bias the patient toward the nurse's opinion (a subtle form of coercion). There is no need for the nurse to advocate for the patient until he makes a decision; this is not the nurse's role at this time.

The nurse would question a prescription for application of cold therapy to which patient? The patient with a: a) Wound oozing blood b) Sprained wrist c) Infected wound d) Pressure ulcer

ANS: D The patient with a pressure ulcer would not benefit from a cold application because it would slow blood supply and wound healing and increase risk of further tissue damage. A cold pack may be used for the patient with active bleeding because it causes vasoconstriction and would reduce bleeding. Cold therapy is appropriate for the patient with a sprain to reduce edema, inflammation, and pain. Application of cold slows bacterial growth, so this may be used for an infected wound that is warm to the touch and inflamed.

24. Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: a) Remove all of the soiled dressings before beginning wound treatment b) Cleanse wounds from most contaminated to least contaminated c) Treat wounds on the patient's side first, then the front and back of the patient d) Irrigate wounds from least contaminated to most contaminated

ANS: D To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.

A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate? a) Assume the patient is confused and give the blood anyway. b) Request a psychological evaluation to ensure that the patient understands the risk. c) Ask family members to intervene and make the patient consent to receiving blood. d) Follow the patient's wishes and do not administer a blood transfusion.

ANS: D You should follow the patient's wishes and do not administer a blood transfusion. There is no evidence of confusion; the patient is competent, is aware of the risk, and has given a valid refusal. The nurse should not assume that a patient is confused simply because of the choice a patient makes. A psychological evaluation is not needed simply because the patient refuses treatment that might result in his death. Family members cannot override a patient's decision. The nurse should respect the patient's decision.