Ethical and Legal Issues
A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signature. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your request."
The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of the hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR. Select all that apply. 1. Complete and file an occurrence report 2. Right-click on the entry and modify it to reflect the correct information 3. Document the correct information and end with the nurse's signature and title 4. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg 5. Document in a nurse's note in the client's record detailing the correct information
2,3,4,5
An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you
The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
Call the nursing supervisor
The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead she receives a sexually oriented photograph. Which is the most appropriate initial nursing action?
Call the nursing supervisor and report the occurrence
The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?
Contact the nursing supervisor
A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates understanding of a violation of this client right?
Observing care provided to a client without the client's permission
The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?
Reassess the client
Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort?
Slander
The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?
The client was found lying on the floor
A client is brought to the emergency department by emergency medical services after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
Transport the victim to the operation room for surgery
Which identifies accurate nursing documentation notation(s)? Select all that apply. 1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 3. The client seemed angry when awakened for vital sign measurement 4. The client appears to become anxious when it is time for respiratory treatments 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema
1,2,5
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?
Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment
