Accountability

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage

A nurse administers digoxin 0.125 mg to a client at 1400 instead of the prescribed dose of digoxin 0.25 mg. Which statement should the nurse record in the medical record?

Digoxin 0.125 mg given at 1400 instead of prescribed dose of 0.25 mg. The nurse should not include judgment statements, opinion, assumptions, or conclusions about what happened. The nurse should simply state the occurrence.

Which would be included as a responsibility of the scrub nurse?

Handing instruments to the surgeon and assistants

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

Provide the client with assistance in transferring to the bedside commode.

Therapeutic communication

Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship. is not intended to cause the child to do what the health care provider requires.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first?

the prescriber

A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:

"I'm going to give your son some insulin. Then I'll be happy to talk with you." Attending to the mother's needs is a critical part of caring for a sick child. In this case however, administering insulin in a prompt manner supersedes the mother's needs. By informing the mother that she's going to administer the insulin and will then make time to talk with her, the nurse recognizes the mother's needs as legitimate.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?

Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. The purpose of a registered nurse's signing off the chart is to ensure that the safety of the client has been assessed. Abnormal vital signs identify that priority systems indicate that a stressor or infection is present.

If the dosage is inappropriate for a client, who is responsible?

Nurse Whereas physicians and other health care providers prescribe and pharmacists dispense therapeutic agents, it is the nurse's legal domain to administer medications in a safe and timely manner.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step?

Read the consent form to the client and ask if there are any questions. The nurse should read the consent form to the client and make sure that the client understands all the information. The healthcare provider should answer any questions the client has before the consent form is signed

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction. It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client.

The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone?

Record "T.O." at the end of the order. Recording "T.O." at the end of the order indicates that this was a telephone order.

The nurse has confirmed the client's identity and provided a client with oral medications to take. What is the next appropriate nursing intervention?

Stay with the client while medications are taken. The nurse must wait with the client to personally acknowledge that medications have been taken (or refused).

Who does the scrub nurse assist and when?

assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment.

When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, the nurse realizes the client doesn't fully understand the surgery. The nurse approaches the physician, who curtly says, "I've told this client all about it. Just get the consent." The nurse should

tell the physician the client isn't comfortable consenting to surgery at this point.

acute phase of the Trajectory Model

the client has severe and unrelieved symptoms or complications that necessitate hospitalization.

Who does the circulating nurse work with?

works in collaboration with other members of the health care team to plan the best course of action for each patient

A heel stick blood glucose on a 6-hour-old newborn is 44 but the venous blood sample shows a glucose of 89. What could cause this discrepancy?

The bedside glucometer is not calibrated for newborns. The bedside glucometer must be calibrated for newborns to accommodate the high hematocrit concentrations of the newborn. Otherwise, false readings may occur.

The pretrajectory phase of the Trajectory Model

one in which lifestyle behaviors place a client at risk for a chronic condition

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply.

- counting sponges before and after surgery - positioning the client on the operating table - monitoring the client's vital signs

autocratic leadership

A form of leadership in which the leader makes decisions on his or her own and then announces those decisions to the group. involves the leader assuming control over the decision and activities of the group.

laissez-faire leadership

A leadership style that leaves much of the business decision-making to the workforce - a 'hands off' approach and the reverse of the autocratic style also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure. Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented.

The nurse is preparing to administer a medication via a syringe pump as ordered for a 2-month-old girl. Which is the priority nursing action?

Verify the medication order The priority nursing action is to verify the medication ordered. The first step in the eight rights of pediatric medication administration is to ensure that the child is receiving the right medication.

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality?

determining that the client has authorized release of the information A nurse must obtain client authorization before sending any confidential information to a nursing home or other facility.

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply.

"The client will be involved in the verification process prior to surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." "The client can be involved in marking the knee, the site for the surgery." There is an increased emphasis on making sure that the right client has the right procedure at the right site. To prevent "wrong site, wrong procedure, wrong person surgery," The Joint Commission (2019) established a universal protocol to achieve this goal. Included in this checklist are steps to verify the preoperative process, mark the operative site, and perform a "time-out."

Which qualities are essential for a community-based nurse? Select all that apply.

- Keen physical assessment skills - Effective communication skills - Strong knowledge foundation Community-based nurses must possess several key qualities: they must be knowledgeable and skilled in their practice (including strong and effective communication and physical assessment skills), able to make decisions independently, and willing to remain accountable.

The nurse manager is reviewing medication order protocols with staff nurses. Which teaching will the nurse include? Select all that apply.

- Nurses and health care providers are accountable for drug safety. - Refrain from using abbreviations. - Be mindful of look-alike and sound-alike drugs. The nurse manager's teaching will include that health care providers must sign all orders, and care must be taken with look-alike and sound-alike drugs. Abbreviations should not be used. The nurse and health care provider are both accountable for drug safety.

A client has been diagnosed with Parkinson's disease and the primary health care provider has prescribed levodopa(100 mg)-carbidopa(10 mg) PO q8h. What is the nurse's best action?

Administer the medication as prescribed and monitor for therapeutic and adverse effects This prescription is within recommended parameters. The nurse should administer the medication and monitor the client.

A nurse records a client's fingerstick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that the wrong client was tested and given insulin. What is the nurse's priority action related to this incident?

Assess both clients, and call the appropriate healthcare providers to notify them of the errors. The nurse must acknowledge the mistake and take all necessary actions to prevent or minimize harm arising from the incidents. This includes assessing the clients for complications of the error and notifying the healthcare providers to receive further direction in correcting the error.

The registered nurse (RN) is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which task would be appropriate for the RN to delegate to the UAP?

Assessing oxygen (O2) saturation When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of the condiiton, and the potential for harm. Assessing O2 saturation is within the scope of a UAP.

The nurse is reviewing the physician's order written for a postmenopausal client: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order?

Clarify with the physician that the spray should be given in only one nostril per day. Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print "administer in both nostrils" when a nasal spray is ordered. Nurses must be familiar with the directions for each medication they give before administering medications.

A nurse is admitting a 7-year-old child to the pediatric unit of the hospital. While the nurse is showing the child and parents the room and explaining where things are, the child becomes upset and frightened. What is the best action by the nurse?

Go slowly with the acquaintance process. The child who reacts with fear to well-meaning advances and who clings to the caregiver is telling the nurse to go slowly with the acquaintance process. The child who knows that the caregiver may stay is more quickly put at ease. To provide security for the child and to provide family-centered care, it is the responsibility of the nurse to form good partnerships with families

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating?

Integrity The principle of integrity is based on the honesty of a nurse according to professional standards. In this instance, the nurse reported the occurrence of the missed medication to the charge nurse.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order. A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

Provide the client with assistance in transferring to the bedside commode. Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response?

State, "I cannot give medications for other nurses." Nurses must never administer medications prepared by another nurse. Nurse B will professionally reply, "I cannot give medications for you."

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?

Surgeon The registered nurse first assistant practices under the direct supervision of the surgeon.

Which of these statements regarding a nurse manager role is accurate?

To effectively manage the nursing unit, the nurse manager should also be a leader. In order to be an effective nurse manager, the nurse manager must also be a leader. This is important with management of a healthy work environment, which is a responsibility of the nurse manager. This is done by helping ensure that interpersonal conflicts are resolved. The nurse manager is also accountable for client census, staffing, supplies, and budget, but is not responsible for setting financial targets for the budget; this is usually managed at the executive level.

The nurse is working to gain a preschooler's cooperation to swallow an oral medication. What would be the nurse's best approach?

ask if the child would like to take the medicine in a cup or through an oral syringe The preschool age is when the child develops initiative. This is the sense that the child is helping. Thus, the nurse should allow the child ot participate in the medication task. The instructions and choices need to be simple.

A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should

notify the physician that the client doesn't understand the procedure. Informed consent requires that four essential elements be satisfied: competence, adequate disclosure, sufficient comprehension, and client voluntariness. The client must be mentally competent to give consent. The client must receive adequate information on which to base an informed decision.

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?

procedural pause (time-out) The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.

The client who has the chronic condition of diabetes, reports blurry vision, and admits to nonadherence to the diet and medications. The home health nurse checks the client's fasting blood glucose level, which is 412 mg/dL. What phase of the Trajectory Model of Chronic Illness does the nurse assess this client is in?

Acute In the acute phase of the Trajectory Model of Chronic Illness the client has severe and unrelieved symptoms or complications that necessitate hospitalization. The client's blood glucose level is high enough that hospitalization may be required.

In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant?

"Dispose of the disconnected IV set." The statement, "Dispose of the disconnected IV set" is in accordance with the delegation guidelines of right communication. The nurse should provide all the necessary information to carry out the assigned task.

When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history?

"Have you heard that some teens like to smoke? Have you tried this?" When obtaining a health history from teens, the nurse should approach questions about sensitive subjects in a nonthreatening manner. This method may encourage the teen to not be afraid to ask questions and be more open

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

"I will not work tomorrow because I would be a danger to my clients." The nurse cannot care for client without first ensuring self-care. The nurse is tired and most appropriately is declining to work because the nurse will not be able to function at full capacity.

A client of a homecare nurse gives the nurse an envelope with a small amount of money in it, stating, "It's a tip for the good care you give me." Which statement would be the most appropriate response from the nurse?

"I'm grateful that you're satisfied with the care you're recieving, but I can't accept any form of gift." Because the nurse is in a position of power, it would be an abuse of power to accept the gift; specifically, it would be considered financial abuse. This is also true of non-monetary gifts

The nursing supervisor is preparing to delegate some aspects of the nursing care plan interventions to other healthcare providers on the unit. Which are the responsibilities of nursing supervisors? Select all that apply.

- Ensuring that care is delivered accurately and appropriately - Knowing the job descriptions and capabilities of each person on the team in depth - Assigning to registered nurses rather than nonprofessional staff the practice-pervasive functions of assessment Nursing supervisors must know the job descriptions and capabilities of each person on the team in depth.

A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN?

9-year-old child receiving subcutaneous insulin for diabetes mellitus The unit manager should assign the LPN/VN to the child with diabetes mellitus. Because the client is receiving subcutaneous insulin rather than IV insulin, the diabetes is likely stable. Meningitis is an acute condition with the potential to progress into respiratory depression and seizures; this child will require frequent nursing assessments. The child who had a tonsillectomy remains at risk for hemorrhage during the first 24 hours following surgery.

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?

Address the nurse's omissions as negligent behavior. Negligence refers to careless acts on the part of an individual who is not exercising reasonable or prudent judgment. It also refers to the failure to do something that a reasonable person (another nurse) would do.

A client is received into the emergency department after getting shot in the chest. The client is hemorrhaging profusely and is in hypovolemic shock. The nurse calls a code blue. What type of leadership style will be most effective during the management of the code?

Autocratic leadership Autocratic leadership will be most effective in this scenario. Autocratic leadership involves the leader assuming control over the decision and activities of the group. During code blue, a leader is needed to direct the actions needed and make quick decisions to positively affect the client.

A nurse working as part of a genetics counseling team is preparing a presentation for a career day discussion at a local college of nursing. When describing the genomic framework for nursing, which of the following would the nurse include as being most important?

Being keenly aware of one's own attitudes and assumptions about genetics and genomics An awareness of one's attitudes and assumptions about genetic and genomics and how these are manifested in one's own practice is essential to a genetic and genomic framework in nursing.

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met?

Breach of duty Failing to communicate a change in the client's condition reflects a breach of duty. Duty describes the relationship between the person and the person being sued.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant.

The nurse is working with a client who has difficulty controlling her blood sugar. The overweight client does not adhere to a low-calorie diet and forgets to take medications and check her blood glucose level. The client's glycohemoglobin is 8.5%. When establishing a goal for the client, the nurse first

Collaborates with the client to establish an agreed-upon goal When establishing a goal, the nurse should collaborate with the client. The nurse does not dictate to the client what the goal will be.

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs. Equipment such as stethoscopes, sphygmomanometers, and other assessment tools that are used for clients on contact precautions should be cleaned and disinfected before use on other clients.

A nurse is providing care to a client and is preparing the client for breakfast. The nurse assists the client out of bed to the chair and then helps the client open the items on the breakfast tray. The client begins to eat breakfast. The nurse tells the client, "I'll be back in about 10 minutes to check on you. In the meantime, here is your call light in case you need me." About 10 minutes later, the nurse returns to check on the client. The nurse is demonstrating which ethical principle?

Fidelity Fidelity involves keeping promises and being faithful to the promises made. In this case, the nurse tells the client that she will return in 10 minutes and then follows through with the promise.

What is the main benefit of effective therapeutic communication for the nurse-client relationship?

Helps develop trust between nurse and the child. Therapeutic communication involves open-ended questions, therapeutic play, acknowledgement of the client's emotions and active listening, which all help to enhance the nurse-client relationship by building trust between the client and the nurse.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP?

Initiating intravenous therapy When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of that condition, and the potential for harm. Initiating intravenous therapy is reserved for the RN due to the potential for harm and the scope of the UAP

Which teaching statement best exemplifies cultural competence in relation to time for the American culture?

It is important to be on time for your health care appointment.

The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate?

Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. If a consent form is not signed, the nurse should notify the surgeon. It is the health care provider's responsibility to obtain consent for surgery and anesthesia. Preoperative medications cannot be given until the consent form is signed.

Which style of leadership is rarely used in a hospital setting because of the difficulty of task achievement by independent nurses?

Laissez-faire In laissez-faire leadership, also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group.

While caring for a client from a culture different from the nurse's, the nurse inadvertently offends the client. What is the best action by the nurse?

Learn from the mistake and do not repeat it.

A nurse preparing medication for a client is called away to an emergency. What should the nurse do?

Lock the medications in a cart and finish them upon return. Once medications have been prepared the nurse must either stay with the medications or lock them in an area such as the medication cart. The medications should never be left unattended or placed back in their containers. Another nurse cannot administer medications that have been prepared by the first nurse.

Which nursing measure is most effective in reducing newborn infections?

Maintain medical asepsis while providing care. Nurses possess the education and assessment tools to decrease the incidence of and reduce the impact of newborn infections. Nurses should implement measures for prevention and early recognition, including maintaining medical and surgical asepsis for all providing care. Nurses should outline and carry out measures to prevent hospital-acquired infections, such as thorough hand-washing hygiene for all staff.

What is the nurse accountable for, according to state nurse practice acts?

Making nursing diagnoses State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held individually accountable.

A client has a prescription for amoxicillin 500 mg P.O. every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops complications and has an increased length of stay. The client files a lawsuit against the facility and the nurse. Which legal action has the nurse's attorney identified that meets the criteria for the client's lawsuit?

Malpractice The facility and nurse could be charged with malpractice, which is failing to perform (or performing) an act that causes harm to a client. Administering the medication intravenously instead of orally as prescribed has caused harm to a client.

While caring for an infant, the nurse hears another child screaming in the next room and rushes there, forgetting to put the side rails up on the infant's crib. The nuse returns to the room to find that the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for?

Malpractice The nurse did not ensure the safety of the infant by pulling up the side rails before leaving the infant unattended. Therefore, the nurse may be charged with malpractice because the nurse had a duty and breached it, which resulted in harm to the infant.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?

Notify the physician of the oversight. Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as narcotics or barbiturates, can alter cognitive abilities and invalidate informed consent.

Which statement about laws governing the distribution of controlled substances is true?

Nurses are responsible for adhering to specific documentation about controlled substances. Nurses have specific responsibilities regarding controlled substances, including specific documentation. Violation of controlled substances laws at the workplace is serious and a criminal act.

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?

Place the date on the vial and retain for future use. The nurse will place the date on the vial and retain it for future use since the vial is indicated for multiple uses.

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action?

Report the error, complete the proper paperwork, and meet with the unit manager. Making an error can be very stressful and a nurse may feel great pressure to hide the mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next?

The incident report will provide a basis for promoting quality care and risk management. Incident reports document unusual occurrences and deviations from care. Facilities use the internal documents to evaluate care, determine potential risks, or discover system problems that might have contributed to the error. This type of error won't result in a report to the state board of nursing or in the nurse's suspension

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse The question focuses on independent actions that nurses can perform. Interventions for which the nurse may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regimen. Nurses are responsible for alerting the appropriate professional (e.g., the physician) whenever assessment data differs significantly from the baseline.

Which best exemplifies malpractice?

The nurse administers amoxicillin to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest. All elements of liability are in place for the scenario involving a nurse administering amoxicillin to a client with documented allergies to penicillin: the nurse had a duty and breached it by giving the medication (amoxicillin), which caused the client harm (seizures and respiratory arrest).

The pediatric nurse is preparing to administer ibuprofen to an 8-month-old infant. The infant's weight is listed in the computer as 15 kg (33 lb) and the medication is prescribed to be given 10 mg/kg. The nurse notices that the dose of 150 mg seems high for an infant. The nurse clarifies the prescription with the healthcare provider, who states that it is the correct dose. What should the nurse do?

Verify child's weight is accurate and, if it is correct, give the medication. Pediatric medication dosages are weight-based. In this scenario, the nurse has already verified the prescription is correct with the healthcare provider, and 10 mg/kg is a safe and standard dose for ibuprofen in pediatric clients. The nurse should verify the child's weight is accurate, because 15 kg (33 lb) for an 8-month-old infant is higher than the 99th percentile and, if it is accurate, the medication should be given as prescribed.

The nurse is preparing to administer an IV antibiotic to a child. After calculating the recommended dose with the child's weight, the nurse discovers the prescribed dose exceeds the safe dose range in a pediatric drug book. The medication has been given to the child at this dose for 3 days. What action should the nurse take next?

Verify the dose with the prescribing health care provider. Medication calculations should always be checked before giving the dose. When a medication dose is found to be outside of the safe dose range, the dose should be verified with the prescribing health care provider. Doses that exceed the recommended range should always be verified, even if they have been given before. The parents did not prescribe this medication. Even if the medication has been given for 3 days, it does not make the dose correct. Calling the pharmacy can only verify if the dose is out of the safe range.

democratic leadership

a leadership style that promotes the active participation of workers in taking decisions also called participative leadership, is characterized by a sense of equality among the leader and other participants.

Therapeutic play

improves the child's ability to cope.

Transformational Leadership

leadership that, enabled by a leader's vision and inspiration, exerts significant influence described as charismatic; transformational leaders are unique in their ability to inspire and motivate others.

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant.

The comeback phase of the Trajectory Model

one in which there is a gradual recovery to an acceptable way of life.

A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to

the social worker on call. The social worker on call knows how to make a referral to authorities without violating the client's rights. The nurse does not need to contact the physician because the physician would also refer the client to the social worker.

The stable phase of the Trajectory Model

characterized by symptoms of illness being under control.

Which statements by the nurse demonstrate understanding of the appropriate way to document an error in charting?

"If I make an error, I draw a single line through it and put my initials by it." Draw a single line through an incorrect entry, and write the words "mistaken entry" or "error in charting" above or beside the entry and sign. Then rewrite the entry correctly. Do not use red ink

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alfa as alternatives to a blood transfusion. Which response by the nurse causes the supervising nurse to plan a review of professional and ethical standards?

"You should take the unit of blood. It will help you feel better." This answer does not allow for client choice because the nurse is influencing the choice. This is a violation of professional and ethical standards.

A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply.

- Take baseline vital signs. - Initiate an IV with normal saline. - Have two nurses check the blood type and identity.

A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs?

Consult reference materials to determine the normal vital signs for 1-month old infants. It is part of nursing practice to interpret the significance of assessment data by comparing it to standards. The nurse should consult reference materials to determine the normal range of vital signs for this client.

A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask?

Are you comfortable performing the tasks assigned? Because the float nurse is not familiar with staff, it is important to ask the other staff if they are comfortable and had instruction in the task assigned. Principles of delegation state that the right task in the right situation by the right personnel is essential to client care.

A new nurse is preparing to dispense medications to the assigned clients. The medications are provided by the pharmacy in individualized single-dose packaging. Which step is most important to ensure that each client receives the correct medication?

Compare the prescriber's original order with the label on the pharmacy package. The only way to determine the accuracy of the medication on hand is to verify it against the original order.

The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action?

Contact the health care provider for order clarification. The nurse should contact the health care provider to verify the order. Bupropion and buspirone are drugs that have look-alike and sound-alike properties but are different in indication.

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation?

Create the client assignment by considering available staff's skill level and client needs. When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members. The charge nurse's primary duty is to the safety of the clients.

A client tells the visiting community health nurse that another client's name and phone number were seen on the call display after the previous day's nurse used the client's home phone. What should the nurse do in response to this conversation?

Discuss the matter with the other nurse, reminding the other nurse not to use the client's phone because it has a call display feature. Leaving personal information in view of other people is a breach of confidentiality. The nurse should inform the other nurse of the incident.

A client is admitted to the hospital and undergoes a lumbar puncture (LP) for cerebrospinal fluid analysis. Approximately 1 hour after the procedure the client reports a severe headache. What is the nurse's priority action?

Increase both I.V. and oral fluids as ordered The nurse should increase both I.V. and oral fluid intake because the headache is usually caused by cerebrospinal fluid leakage. A blood patch would help with pain, but this is not in the nurse's practice act.

A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is most appropriate for the nurse-manager to take?

Meet with the new nurse and the primary nurse and help set up an additional week of orientation. The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation does not mean that a nurse is not competent or that there are deficits in performance. Although a 6-week orientation may be standard, orientation periods should be individualized to meet the needs of the staff as well as provide the best client outcomes.

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions. It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all of the client's questions are answered fully.

A nurse conducted a health history with a 5-year-old child admitted with abdominal pain. The nurse stood at the bedside while talking to the parent and child. The client was in a private room. The nurse made sure the door was closed and referred to the parent as "Mrs. Smith" whenever asking a question. Which action by the nurse was not conducive to the health history?

Standing at the bedside An interview is best conducted in a private room with all parties seated. If not, then the health care worker appears rushed and cannot interact at eye level. When all parties are seated the nurse is demonstrating a relaxed and welcoming manner.

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?

Surgeon The registered nurse first assistant practices under the direct supervision of the surgeon. The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment.

A home care nurse is planning to visit a 60-year-old client diagnosed with heart failure for the first time. Which of the following would be most appropriate for the nurse to do?

Telephone the client to obtain permission to visit. When planning an initial visit, it is imperative that the nurse contact the client and obtain permission to visit first. The home care nurse is a guest in the client's home and must have permission to visit and give care. During this contact, the nurse would also schedule a time for the visit and verify the home address. Additionally, the nurse could also check with the client about his living situation in case special arrangements need to be made to enter the home.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager?

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible

What is the primary purpose of standards of nursing practice?

to ensure knowledgeable, safe, comprehensive nursing care Each nurse is accountable for his or her own quality of practice and is responsible for using standards to ensure knowledgeable, safe, comprehensive care.

A nurse is preparing to start an intravenous (IV) line in a child with severe pneumonia. The nervous child asks the nurse to wait until later to do the procedure. What is the best option for the nurse?

Use a firm, positive, confident approach when starting the IV. When a procedure is necessary the nurse should use a firm, positive, and confident approach that provides the child with a sense of security. The child should be allowed to express feelings of anger, anxiety, fear or frustration but also know the procedure is necessary. In atraumatic care, the nurse should use a topical anesthetic at the IV site prior to the IV insertion to minimize pain. The child should also be in the treatment room for the procedure, because the hospital room should be a safe place for the child.

A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first?

Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. The nurse should return to the room to check the client's identification against the medication administration record. If there was an error, the nurse should then complete a variance report in accordance with facility policy and check the remaining medication before administering it to the second client. The client record shouldn't include documentation of a completed variance report. The nurse should inform the charge nurse of the error after confirming that an error has been made.