Management of Care
A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.) "It lists all my assets and how they should be divided among my family after I die." "I should sit down and discuss my wishes for end-of-life care with my loved ones." "A living will must be renewed by a designated family member each time I am hospitalized." "A living will is a legal document that becomes a permanent part of my health care record." "My wishes for end-of-life treatment are stated in writing." "I will need to identify someone to be my health care proxy."
"I should sit down and discuss my wishes for end-of-life care with my loved ones." "A living will is a legal document that becomes a permanent part of my health care record." "My wishes for end-of-life treatment are stated in writing." "I will need to identify someone to be my health care proxy." An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf. A living will does not expire; it remains in effect unless it is changed. A living will does not include information regarding assets or a person's estate.
The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most relevant as the nurse begins employment? "Which physicians will I be more closely collaborating with?" "Which clients should I see as I begin my day?" "Which groups are at the greatest risk for problems?" "Which nursing assistants can I refer clients to?"
"Which groups are at the greatest risk for problems?" Public health nursing is focused on improving the health status of the entire community. Although all the options are good to know, it is most important that the RN understands which groups in the community have the greatest health needs. Public health nurses collaborate with physicians, as well as with other health care providers, to assess and prioritize major health problems in the community. They also assist individuals and families to take action to improve their health status. Nursing assistants provide care for individual clients and families, but this question is more appropriate for a visiting or home health nurse.
A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects appropriate assertive communication? "Please print in the future so I do not have to spend extra time attempting to read your writing." "Would you please clarify what you have written so I am sure I am reading it correctly?" "I cannot give this medication as it is written. I have no idea of what you mean." "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
"Would you please clarify what you have written so I am sure I am reading it correctly?" Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.
All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first? 79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10 70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery 62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8 67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the dressing
62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8 A surgical client using a narcotic PCA is at risk for respiratory depression, which is potentially life-threatening, and therefore the top priority. The other clients need assessment and attention, but the priority is given to the client with a respiratory rate of 8. Some bloody drainage on a dressing is expected after a drain is removed and of course the nurse would monitor this. Constipation is a side effect of narcotics but is not life-threatening. Pain control is also important but does not take priority over respiratory depression.
A Bosnian Muslim woman who does not speak English seeks care at a community clinic. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice? A female interpreter who does not know the client The client's adult daughter A female neighbor of the client who is also from Bosnia A Bosnian male, who is a certified medical interpreter
A female interpreter who does not know the client When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter is needed. But, it may be inappropriate to have a male interpreter for a female client because the client may not be as forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client. The best response is to have a female interpreter who does not know the client.
The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following clients? A young adult who was admitted 24 hours ago for treatment following detoxification An elderly person who was admitted three hours ago with a diagnosis of cyclothymia An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder
A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder These findings suggest depression. The most therapeutic milieu for this client includes double occupancy with someone who has similar issues and/or whose condition is more stable. A secondary consideration is matching roommates' ages as closely as possible, because they potentially would share similar developmental challenges and needs. The most stable client is the one with persistent depressive disorder. Cyclothymia is an illness that's similar to bipolar disorder and disruptive mood dysregulation disorder is characterized by irritability and episodes of extreme, out-of-control behavior.
A client who is unconscious is brought to the emergency department by an ambulance. What document should the nurse give priority to when preparing the care for this client? A notarized original of the advance directive brought in by the partner Orders written by the health care provider in the emergency department The national statement of client rights and the client self-determination act The clinical pathway protocol of the agency and the emergency department
A notarized original of the advance directive brought in by the partner This document specifies the client's wishes of what actions are to be taken when the client becomes unable to make health care decisions. The advance directive often includes a living will and the power of attorney to whom will make the decisions for the client. The next document that would take precedent are the orders written by the heath care provider. The clinical pathways are used to evaluate the client's progress during therapy.
The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM? Top administrators are responsible for establishing plans for problem management It is an incident management technique that focuses on employee retention It is a reactionary approach used to investigate the root cause of a problem All employees participate in systematically working toward common goals
All employees participate in systematically working toward common goals TQM uses a strategic and systematic approach for continual improvement of processes, products, services and the workplace culture. The focus is on improving customer satisfaction. TQM involves all employees, not just top administrators. It is a proactive, not reactive, approach to solving problems.
A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse? Assign the graduated staff nurse to be transferred to another floor for the shift Change the assignment; reassign the client with the lumbar drain to a different nurse Provide an immediate one-on-one, personal in-service about the drain Check with the nurse and the client often during the shift
Change the assignment; reassign the client with the lumbar drain to a different nurse One of the first principles of safe assignments is to match skills with the task. New nurses should not be assigned tasks for which they are not competent. The assignment needs to be changed. The other options simply help support the nurse but may be dangerous for the client. And, of course, the new nurse will need training about caring for a client with a lumbar drain.
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? Clinical specialty certification by an accredited organization Complete and accurate documentation of assessments and interventions Above-average performance reviews prepared by nurse manager Sworn statement that health care provider orders were followed
Complete and accurate documentation of assessments and interventions The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.
A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager? Schedule a staff conference, without the nurse present, to collect information Consult with human resources personnel about the issue and needed actions Confront the nurse about the suspicions in a private meeting Counsel the employee to resign to avoid investigation and rumors
Consult with human resources personnel about the issue and needed actions The nurse manager needs to consult with human resources to determine the proper procedures for documenting and reporting the nurse's behavior. The nurse manager could also consult the EAP if one is available. If the staff nurse is also suspected of diversion, and a written policy exists, the nurse manager would follow these procedures. Attempts should be made to help the nurse with SUD by providing counseling and treatment for this disease.
The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse checks and then confirms that the client is not progressing on any part of the mobility training program. What action is the nurse's priority? Discuss the problem with the client's surgeon Instruct physical therapy to increase treatments to four times a day Inform the case manager of the variance in the critical pathway Contact the family to discuss preoperative mobility problems
Inform the case manager of the variance in the critical pathway Variances in the critical pathway need to be reported to the case manager. Certain goals need to be met to move the client forward in recovery and transfer to an appropriate venue for continued rehabilitation. The RN cannot order physical therapy treatment. Previous mobility problems are not priority post-operatively. The surgeon needs to be informed about the client's lack of progress, but this is not the priority.
The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has been a two car accident with multiple casualties. What action would the nurse take first, before the victims arrive in the ED? Notify the nursing supervisor and request additional staff Activate the disaster plan Prepare the trauma room and select supplies Set up multiple 1000 mL NaCl IV solutions with tubing and notify the blood bank
Notify the nursing supervisor and request additional staff The ED charge nurse needs to assess, supervise and coordinate staff and to maintain full readiness of ED. The priority is for the ED charge nurse to notify the nursing supervisor that additional nursing staff will be needed. Preparing the trauma room will be next. The clients will need to be assessed prior to the administration of any IV solution and/or blood products. There is no need to activate a disaster plan for a two car accident.
The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrate the shared governance model? Staff groups are appointed to discuss nursing practice and client education issues Non-nurse managers supervise nursing staff in groups of units Nursing departments share responsibility for client outcomes An appointed board oversees any administrative decisions
Nursing departments share responsibility for client outcomes Shared governance or self-governance is a method of organizational design. It promotes empowerment of nurses to give them responsibility for client care issues and outcomes with other divisions in the agency.
A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse? Pacemaker insertion on the day shift Report of unstable angina with continuous telemetry monitoring Dopamine IV drip with vital signs monitored every five minutes Tracheostomy of 24 hours with the client showing some respiratory distress
Pacemaker insertion on the day shift The nurse from the float pool should be assigned to care for the most stable client, which is the client who had the pacemaker inserted on the day shift. The other clients are unstable and have potentially life-threatening conditions. In most critical care units, the nurse can titrate dopamine upward or downward; this requires the expertise of the nurse who normally works on this unit. Although tracheostomies are not limited to critical care units, a nurse unexperienced in critical care should not be assigned to the client with a newly created tracheostomy.
The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What action should the nurse take next? Page the attending physician to express the same concerns Administer the medication as ordered Request a consult with the in-house pharmacist Ask another staff nurse to discuss the same concerns with the hospitalist
Page the attending physician to express the same concerns The scenario is an example of the "two-challenge rule." It is the nurse's responsibility to assertively voice concerns at least two times to ensure that it has been heard. If the outcome is still not acceptable, the nurse needs to take a stronger course of action by either contacting a supervisor or the attending physician to express the same concerns. The nurse must be an advocate for the client.
A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) Poor communication among providers Excellent primary care Reconciliation of medications Client health status Family preferences
Poor communication among providers Client health status Family preferences Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care.
The triage nurse identifies that a 16-year-old client is legally married and has signed the consent form for treatment. What would be an appropriate action by the nurse? Refer the teenager to a community pediatric hospital emergency department Proceed with the triage process in the same manner as any adult client Ask the teenager to wait until a parent or legal guardian can be contacted Withhold treatment until telephone consent can be obtained from their partner
Proceed with the triage process in the same manner as any adult client Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years of age.
The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? Teach the initial ostomy care to a client and family members Assess the function of a newly created ileostomy Care for a recent complicated double barrel colostomy Provide stoma care for a client with a well-functioning ostomy
Provide stoma care for a client with a well-functioning ostomy The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN.
The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other staff and visitors. Which approach by the nurse manager is indicated in this situation? Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." Request an immediate private meeting with the health care provider and staff nurse Stay neutral and allow the staff nurse to handle this situation independently Notify the chief nursing officer about the breach of professional conduct
Request an immediate private meeting with the health care provider and staff nurse Assertive communication respects the needs of all parties to express themselves, but not at the expense of being in front of non-involved staff, visitors or clients. The nurse manager first needs to protect clients and other staff from this display of negative behavior and come to the assistance of the nurse employee. Privacy is a priority, as well as limiting the communication to only those involved.
A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care Report to the nurse manager about the witnessed suspicious activity Immediately call security for this breach in client confidentiality Request to see identification and an explanation as to why the woman is viewing client charts
Request to see identification and an explanation as to why the woman is viewing client charts Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation.
A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first? Tension pneumothorax with slight tracheal deviation to the right Viral pneumonia with atelectasis Spontaneous pneumothorax with a respiratory rate of 38 Acute asthma with episodes of bronchospasm Incorrect
Tension pneumothorax with slight tracheal deviation to the right Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side and cyanosis with a high risk of cardiac tamponade and cardiac arrest.
The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.) The UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday The UAP applies moisture barrier cream to the client's excoriated perianal area The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor
The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee replacement surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail polish.
A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medications." The nurse should respond with an understanding of which statement? The client has a right to know about the use and side effects of the prescribed medications Such education is an independent decision of the individual nurse whether or not to teach clients about their medications Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication's uses and side effects A referral is needed to the psychiatrist who should provide the client with answers to the request
The client has a right to know about the use and side effects of the prescribed medications Clients have a right to informed consent, which includes detailed information about medications, treatments and diagnostic studies. The other options are incorrect approaches.
The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority ethical consideration that can help guide the nurse? Cultural sensitivity is fundamental to pain management The client's self-report of pain is the most important consideration Nurses should not prejudge a client's pain using their own values Clients have the right to have their pain relieved
The client's self-report of pain is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. This is why the self-report is the most reliable way to determine a client's pain. Nurses should apply ethical standards, such as respect for autonomy (the right of people to make their own decisions about healthcare), when assessing pain. The other statements are correct but they are not the most important considerations.
The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? There won't be any consequences because the information was posted on a website for nursing professionals The nurse could be reprimanded for not clearing the information first with hospital administration There won't be any consequences because the client's real name was not used The nurse could be fired for breach of confidentiality
The nurse could be fired for breach of confidentiality Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy.
The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time? In a speaking tone of voice, explain: "The tubing is probably in the vagina." Ask the student in a calm voice: "Did you do something wrong?" State strongly: "Stop. Tell me why there's no urine in the tubing." Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter."
Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter." When no urine appears after inserting a catheter into a female client, the catheter may be in the vagina. This catheter can be left in place and used as a landmark indicating where not to insert the new, sterile catheter. The best approach is for the nurse is to calmly remind the student about this technique and offer assistance. The other options are unprofessional and/or they may upset the client and the student.