Accountability

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 of the following steps 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 other options do not check the original order with the medication that is to be administered to the client.

A 13-year-old is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do?

Verify that the site, side, and level are marked. As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.

A client was admitted to the coronary care unit (CCU) two days ago with an acute myocardial infarction. Which action would breach client confidentiality?

The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress. The ED nurse is no longer directly involved with the client's care, and has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call provider) has the right to information about his condition. Because this client asked the nurse to update his wife, doing so doesn't breach confidentiality.

On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response?

"To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here." The client has the right to confidential treatment, and the nurse has a duty to protect his confidentiality. Stating that to protect clients' confidentiality no information will be given is a diplomatic response. Although simply telling the caller that information can't be released protects the client's confidentiality, this response isn't as diplomatic as the first response. Stating that the client isn't accepting phone calls or that the client didn't sign an information form with the caller's name on it divulges the client's whereabouts and status, violating confidentiality.

A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP?

"Your behavior in this situation is considered verbal abuse." Reprimanding a client for something that is beyond the client's control is considered abusive. The other options do not help the UCP understand the abusive behavior.

A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which of the following would be considered subjective data?

"Client seems very nauseated." This statement is subjective because it is the nurse's interpretation. The other options are incorrect because they reflect objective data.

The supervisor is performing a chart review. The nurse can be held legally liable for which documentation?

1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN There is a cross-sensitivity between cephalosporin and penicillin, and the drug should not have been given. When a dosage range is ordered, any dose in that range is acceptable. Digoxin is a cardiac glycoside that acts to improve the efficiency of the heart and may slow the heart rateand the drug should not ordinarily be given if the apical pulse is less the 60. Mononitrate is a Nitrate that can cause vasodilation and should not be given when hypotension is present.

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.

At the beginning of a shift, the team leader notices that all of the IV antibiotics for a client are still in the medication room. What is the team leader's first action?

Ask the nurse assigned to this client about the medications The team leader should attempt to clarify this matter with the assigned staff first. The client would not be an accurate source of information regarding the IV medications. Returning the supplies is secondary to ensuring that the client received the required medications.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse?

Contact the nurse educator for an in-service and support in performing the skill The nurse has a responsibility for recognizing his/her limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide inservice and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in his/her learning or expertise.

A postpartum client's partner asks to read the client's medical record. He claims to be a nursing student and that reading it would be a learning opportunity. What action by the nurse is most appropriate?

Explain that, for client confidentiality reasons, he can't review the medical record. The nurse should explain that for confidentiality reasons he can't review the medical record. Some facilities permit family members to review the client's medical records in the presence of staff, but only with the client's permission and a physician's order.

A nurse suspects that a coworker is self-administering illegal drugs during work hours. What is the first action the nurse should take?

Notify the nurse manager and document the situation. The nurse has the responsibility to notify the manager of any behavior that puts clients at risk or is against hospital, legal, or professional standards. The nurse may want to confront the second nurse at some point, but this is not one of the options provided. The other options are not correct because they neither address the situation nor protect client safety.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the physician 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 him if he has any questions. The nurse should read the consent form to the client and make sure that he understands what was read to him. The physician and nurse should answer any questions the client has before he signs the consent form. The client's family doesn't need to be present. The legally blind client may sign the consent form.

A nurse working in the operating room is assigned to the suite where therapeutic abortions are to be performed throughout the day. The nurse feels that participation in these procedures conflicts with personal religious beliefs. What should the nurse do after notifying the operating room supervisor?

Remain in the operating room suite until another nurse arrives to take that assignment. If nursing care is requested that is contrary to the nurse's personal values, the nurse must provide appropriate care until alternative care arrangements are in place to meet the client's needs. The other options are not correct, and if the nurse left the suite, it could result in the accusation that the nurse abandoned the client. The nurse should be aware of potential conflicts before accepting an assignment.

The nurse is caring for a client with a PICC line that requires flushing. The nurse has not previously performed this skill. What is the most appropriate action by the nurse to ensure safe care?

Request a different client assignment and arrange a session on the care of a PICC line. The nurse recognizes that he/she lacks the knowledge, skill, and competency to flush the PICC line and needs further education. Gaining the appropriate knowledge, skill, and competency to complete this skill will require further education and practice, not just a bedside session. The other options are incorrect because they are neither appropriate nor safe and do not address the nurse's need for further education.

Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task?

Scheduling staff assignments for the next month Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff, who don't have the power and authority to take such actions.

A nurse notices the smell of marijuana on a nursing colleague upon return from lunch break. The colleague is having difficulty drawing up a dose of insulin, appears uncoordinated, and is unaware that the needle has been contaminated. What is the best action for the nurse to take?

Stop the colleague from drawing up the insulin. Notify the supervisor about the incident, and document the observations. Acknowledging that there is a problem and protecting the client is a professional responsibility. Calling the supervisor is important so the client can be reassigned and the supervisor can deal with the problem. Taking over the nurse's responsibilities is not appropriate. The problem then will not be addressed. The incident needs to be reported because client care is in jeopardy.

A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations, and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations, and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse?

The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization. The nurse can document the interaction but does not need to escort the caregiver and child out of the office. The nurse should not plead his or her opinion and forcefully inject the child without permission. The nurse is responsible for communication refusal, but asking the provider to return is not necessary as the caregiver has the right to refuse immunizations for his or her child.

A staffing agency is sending a licensed practical nurse (LPN) to cover a shift for a pediatric nurse who called out sick. The unit's nurse-manager isn't familiar with the LPN's clinical background or comfort level with pediatric clients. The nurse-manager should assign the LPN to:

a 9-year-old child receiving subcutaneous insulin for treatment of diabetes mellitus. The nurse-manager should assign the LPN to the child with diabetes mellitus. Because he's receiving subcutaneous insulin rather than I.V. insulin, his diabetes is likely stable. Reye's syndrome is an acute condition with the potential to progress into respiratory depression, seizures, loss of deep tendon reflexes, or other neurologic deficits. 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. Legg-Calve'-Perthes Disease is associated with impaired circulation to the femoral capital epiphysis. This condition requires aggressive monitoring.

The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give "hand-off reports" at which times? Select all that apply.

change of shift change of nurses when the nurse goes to lunch Effective communication is essential when managing client safety and preventing errors. "Hand-off reports" should be made at shift change, when there is a change of nurses or when the nurse leaves the unit, and when the client is discharged or transfers to another unit. There does not need to be a handoff report when the unit clerk leaves the unit or when new medication prescriptions are written.

After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom she's assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response?

Ask the student to provide a photo ID for comparison with the names on the assignment sheet. Most facilities require photo identification to maintain security and confidentiality. Allowing a student without an ID to have supervised access to a medication record doesn't protect client information. Contacting the instructor by phone doesn't verify the student's identity.

The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. What action should the nurse take first?

Assess the client's injury, notify the physician, and document the incident. The nurse should assess the injury, notify the physician, and thoroughly document the incident in accordance with hospital protocol. Even though a patient with somatic symptom disorder is likely to have many physical complaints, the nurse should thoroughly investigate each complaint to avoid overlooking a serious problem. The nurse should always notify the physician of her findings in accordance with facility protocol.

During an emergency, a physician has asked for I.V. calcium to treat a client with hypocalcemia. The nurse should:

Check with the physician for his complete order The nurse should first check with the physician for the complete order of calcium because calcium chloride has a concentration of 13.6 mEq (3.4 mmol/l) of calcium per gram and calcium gluconate has 4.65 mEq (1.2 mmol/l) of calcium per gram. The nurse can always offer the doctor the type of calcium available after the conversion in calcium has been made; otherwise, the error could be fatal.

While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which response by the nurse would be most appropriate?

Explain to the client that "Nurses are not allowed to discuss other clients on the unit." Legal regulations and ethical decision making require that the nurse maintain confidentiality at all times. The nurse's best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client's question is inappropriate because doing so would interfere with the development of a trusting nurse-client relationship. Confidentiality must be maintained at all times. Telling the client that the nurse is not sure may imply that the nurse will find out and then tell the client about the other woman. Asking the other woman's permission to discuss her with another client is inappropriate because confidentiality must be maintained at all times.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

Making a copy of the incident report for the client A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the physician of the incident and the client's condition.

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescriber. A nurse who has omitted an ordered medication should prioritize the notification of the prescriber. She should then document the omission and the reason it occurred in the client's chart and, depending on facility policy, write an incident report. Depending on the facility's policy, the nursing supervisor may need to be notified, but this would be done after the prescriber has been notified.

A nurse meets his/her neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts?

Share the feedback with the nursing colleague directly. It is not a breach of confidentiality for the nurse to share the feedback with the colleague, and by doing so the nurse will recognize the value of the colleague's professional efforts and accomplishments. It is not appropriate to place an announcement at the nurses' station or to send an anonymous card. It is crucial that nurses uphold the standards for professional practice and consider the American Nurses Association (Canadian Nurses' Association) Code of Ethics, in particular surrounding the principles of preserving dignity and maintaining privacy and confidentiality.

A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse?

Refuse to administer the placebo to the client The nurse should refuse to give the placebo and should also refuse to misinform the client. The nurse has a responsibility to explain the client's medications to the client. The client can then make an informed decision about accepting or refusing the medication. The other options are incorrect because the nurse would be misinforming the client about the medication that is being administered. The client would not be able to provide informed consent.

A client is prescribed a newer oral diabetic medicine. The client returns for a follow-up visit and starts to describe a variety of ailments the client had with the medicine. The nurse questions the client and asks where the client obtained the information. The client says that the client read a daily blog about the medication on the internet and all the bloggers complained of the same symptoms. Which statement is important for the nurse to include in teaching about the medication?

Reliable sources of information, such as one's prescriber and the CDC, are encouraged. The client should be referred to the prescriber. In addition, the client should be taught that reliable sources on the internet provide accurate medical information such as the CDC. Blogs are great ways to discuss issues but they are not a reliable source of information.

A nurse who is working with a nursing assistant is making care assignments for the shift. Which task would be most appropriate for the nurse to delegate to the nursing assistant? Select all that apply.

checking vital signs documenting oral intake on the I&O;flow sheet assisting with a bed bath for a client who had surgery yesterday When delegating client assignments and tasks, the nurse must make sure that the tasks assigned meet the training and educational level of the person to whom the task was assigned. It would be appropriate for the nurse to assign tasks such as checking vital signs, documenting oral intake, and assisting with hygiene measures. Evaluating a client's response to pain medication and assessing a client's bowel sounds are higher level, skilled tasks that the registered nurse must perform.

The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a birthing center. Which tasks should the nurse delegate to the UAP? Select all that apply.

removing a Foley catheter from a preeclamptic client assisting an active labor client with breathing and relaxation ambulating a postcesarean client to the bathroom The UAP could assist the client with breathing and relaxation, and ambulate the postcesarean client to the bathroom. UAP can also remove Foley catheters in uncomplicated clients. Calculating the hourly IV totals for a preterm labor client would involve assessments that require nursing expertise. In-and-out catheterization, a sterile procedure, and calling reports to HCPs, which requires gathering and analysis of data, are responsibilities of the nurse.

The nurse is reviewing the following physician's order written for a postmenopausal woman: "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. The other options are incorrect because calcitonin salmon nasal spray is prescribed to postmenopausal women for the treatment of osteoporosis and requires a physician's order.

A nurse administers digoxin 0.125 mg to a client at 1400 instead of the prescribed dose of digoxin 0.25 mg. Which of the following statements 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. The other options present judgment, blame, and conclusion.

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation?

Discuss the situation with the first nurse, including the safety implications of sleeping on the job. The second nurse is responsible for immediately discussing this behavior and its safety implications with the first nurse. The other options do not demonstrate behavior representative of advocating for safe and competent care.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation?

Notify the supervisor and call the police. The supervisor should be made aware of the situation and the police should be called to investigate the potential theft. The other answers do not advocate for the clients and their families. It is the responsibility of the nurse to take action because the nurse was the person to receive the information. This is known as due diligence.

In which way does a nurse play a key role in error prevention?

Identifying incorrect dosages or potential interactions of ordered medications The nurse must be knowledgeable about drug dosages and possible interactions when administering medications; she must follow appropriate policies to correct dosage errors or prevent potential interactions. The nurse is responsible for questioning unclear or ambiguous physician's orders and should never carry out an order with which she's uncomfortable. OSHA establishes comprehensive safety and health standards, inspects workplaces, and requires employers to eliminate safety hazards but notifying OSHA of medication errors doesn't resolve the problem. The client should be aware of his rights as a client, but that awareness doesn't play a key role in error prevention.

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?

Notify the supervisor and provide care until another nurse can be assigned to the client. The nurse should notify the supervisor of the relationship with the client and ask to be reassigned. If no other nurse is immediately available, the nurse should provide the necessary care until another nurse can assume responsibility for the aunt's care. The other answers are incorrect because the nurse may not be able to ensure that the therapeutic nurse-client relationship can be maintained when caring for a family member.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent. All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed. The nurse should take the client to the operating room.

Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system include:

documenting the client's response to pain medication It is essential that the nurse document the client's response to pain medication on a routine, systematic basis. Reassuring the client that pain will be relieved is often not realistic. A client who continually presses the PCA button may not be getting adequate pain relief, but through careful assessment and documentation, the effectiveness of pain relief interventions can be evaluated and modified. Pain medication is not titrated until the client is free from pain but rather until an acceptable level of pain management is reached.

A charge nurse asks a group of staff nurses to cover part of the next shift because a nurse called off. A staff nurse states, "40 hours a week of nursing is all I can manage. I won't volunteer for overtime." The charge nurse tells the unit's nurse manager, "You should adjust her schedule to make her wish she'd volunteered." How should the nurse manager respond?

Counsel the charge nurse about her comment. It would be discriminatory and punitive for the nurse manager to alter the staff nurse's schedule. The remark by the charge nurse is inappropriate and unprofessional, and the charge nurse should receive counseling. The nurse manager could choose to ignore the comment, but any leader who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the charge nurse to the nursing administration should be avoided. Institutional documentation should exist for such matters. It is inappropriate for the nurse manager to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first?

Discuss the breach of practice with the physician. The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step.

A nurse observes a second nurse documenting a peripheral blood glucose level that the second nurse did not actually collect from a client with diabetes. What is the priority action by the nurse observing this situation?

Discuss the observation with the other nurse. The first action the nurse should take is to discuss what was witnessed with the other nurse and express concern that this behavior is unethical, unprofessional, and illegal. The nurse manager should be notified in order to follow up with the nurse. Documenting assessments that were not actually done on a legal document is illegal and constitutes professional misconduct. The other options do not reflect safe and competent care, nor do they protect the client.

A client who has been treated initially in the emergency department for a leg wound from a fall is waiting for care provider evaluation. The client says, "I am tired of waiting, and I am going to leave." The nurse explains that it is important to wait to ensure that there are no other injuries. The client tells the nurse, "I am going to leave. I am not waiting around here any longer. My leg is fine." Which response by the nurse would be most appropriate?

Notify the care provider of the client's intent to leave. When a client wants to leave a facility, he or she is legally free to do so, even though such actions carry an increased risk for problems. The nurse has already attempted to explain the importance of staying, so the next step would be to notify the care provider who should then reinforce the need to stay for an evaluation. If the client continues to voice the desire to leave, the client should sign a form that releases the care provider and facility from any legal responsibility for the client's health status. Calling security to block the client's exit is inappropriate and would be considered false imprisonment. Warning the client that he or she will be restrained is threatening and also considered false imprisonment.

A nurse arriving for duty notes that a nursing assistant (or unregulated care provider [UCP]) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UCP?

Reassign the UCP to a client requiring basic tasks that the UCP has mastered. The nurse is accountable for the delegation of tasks to UCPs. The nurse delegates tasks to UCPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UCPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UCP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UCP has the knowledge and skill to provide the care or carry out the task.

A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should:

initiate a time-out. The Universal Protocol is used to prevent wrong site, wrong procedure, and wrong person surgery. Actions included in the protocol are as follows: conduct a preprocedure verification process, mark the procedure site, and perform a time out. Exceptions to the Universal Protocol are routine or "minor" procedures, such as venipuncture, peripheral IV line placement, insertion of oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the surgeon or circulating nurse will initiate a time out to verbally confirm a review of informed consent and procedures completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies have been removed. The Chief of Surgery and Medical Director are the ones who will verify the surgeons' levels of expertise.

A nurse fails to give the evening dose of an IV antibiotic that is to be administered every 12 hours. The evening dose was scheduled for 1800; it is now 2200. The nurse should next:

report the incident to the health care provider. The error must be reported to the health care provider to obtain a new scheduling prescription. An incident report should be completed, and the agency policy for medication errors should be followed. Assessing for signs of infection is not the nurse's first action and should be completed routinely for clients receiving antibiotics. The dose should not be administered 4 hours late unless prescribed by the health care provider; a new medication schedule will be arranged. The pharmacist is not responsible for giving directions for medication omissions; this is the responsibility of the health care provider.

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that she forgot to administer insulin to client with diabetes mellitus. She's made numerous errors in the past few weeks and is now afraid her job is in jeopardy. What is her 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 her 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. Nonetheless, she must still report the error and complete the proper paperwork. The nurse should contact the physician and follow his instructions, but she shouldn't bypass proper protocol.

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. This information includes the nature of the procedure, expected benefits and positive outcomes of the procedure, potential risks or negative outcomes of the procedure, potential risks if the client chooses not to have the procedure, and available alternative therapies and their risk and benefits. The client must sufficiently comprehend this information and must be free to decide without coercion. The physician or the person who will perform the procedure is responsible for securing informed consent. A nurse witnesses the client's signing of the consent form and validates his identity, mental status, and voluntary signature.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which of the following is a correct component in the nursing plan of care?

Documenting the situation and providing support for the victim The nurse must carefully and adequately document her assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. She should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.