Nur 115: Midterm

Which statements made by a nurse would indicate to a nurse manager that the nurse requires further training? Select all that apply. "If I make a mistake, I will not tell anyone." "When I document, I make sure it is factual, accurate, complete, and timely." "I will have the supervisor fill out the incident report when I make an error." "I am accountable for any task that I delegate." "The nursing plan of care must be accurate and must be followed. It is part of the client's permanent record."

"If I make a mistake, I will not tell anyone." "I will have the supervisor fill out the incident report."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse?

"Take it with you. It is recognized universally in the United States."

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement?

"The rules made by the board of nursing don't reflect my practice."

The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document?

A living will; a living will is an advanced directive that specifies the type of medical treatment clients do or do not want to receive should they be unable to speak for themselves in a terminal or otherwise unconscious condition.

Which scenario is an example of certification?

A nurse who demonstrates advanced expertise in a content area of nursing through special testing

Which nursing student would most likely be held liable for negligence?

A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action?

Assess the client's back visually.

A client admitted to a mental health unit has exhibited physical behaviors that put the client and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which action?

Battery

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?

Document the client's claims and the events surrounding the alleged incident.

In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws?

Emergency care for a choking victim in a restaurant

An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed?

Invasion of privacy

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

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

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

Nurses are responsible for adhering to specific documentation about controlled substances.

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?

Prioritize the nursing diagnoses.

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

Repositioning the client

5 Rights of Nursing Delegation

Right Task Right Circumstance Right Person Right Supervision Right Direction and Communication

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis?

Risk for falls

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

A client is newly diagnosed with diabetes and prescribed insulin injections. The nurse identifies the client's knowledge deficiency regarding insulin injection. Which intervention is appropriate to address this deficiency?

Teach the client how to administer insulin.

A family brings the client to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse confirms that the client's family has signed the consent form.

After reporting to work for a night shift, the nurse learns that the unit is understaffed because two RNs called out sick. As a result, each nurse on the unit must provide care for four acute clients in addition to the nurse's regular clients. Which statement is true for this nurse when working in understaffed circumstances?

The nurse is legally held to the same standards of care as when staffing levels are normal.

A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation?

The nurse should call and inform the nursing supervisor of the situation.

A client newly diagnosed with congestive heart failure has a prescription for digoxin. The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care?

The nurse withholds the medication and notifies the health care practitioner. Explanation: Nurses are responsible for following the standards of care for their particular work area. A reasonably prudent nurse would withhold the medication and notify the health care practitioner. All other options put the client's safety at risk and would not be done by a reasonably prudent nurse.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

To evaluate the quality of care provided and assess the potential risks for injury to the client

Professional regulations and laws that govern nursing practice are in place for which reason?

To protect the safety of the public.

Nurses are occasionally asked to witness a testator's (person who makes the will) signing of a will. Which guideline is true regarding a nurse's role in witnessing a testator's signature?

Witnesses to a signature do not need to read the will.

Which process evaluates and recognizes educational programs as having met certain standards?

accreditation

A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. The charge nurse appropriately identifies that nurse has committed:

battery

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor?

battery; an assault that is carried out and includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to that other person.

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete the postoperative assessment.

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

involving the client with all the steps of the process in care development

A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as:

life-sized mannequins with a sophisticated computer interface.

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.

A nurse becomes concerned that a coworker may have a substance use disorder. Which behaviors by the coworker would increase this concern? Select all that apply. 1. The last two times the nurse has needed help turning a client, the coworker could not be found. 2. The coworker has needed to leave early "to pick up my kids" several times in the last 2 months. 3. The coworker mentioned going to the primary care provider's office twice in the last month. 4. The coworker has stopped eating lunch in the breakroom with other nurses. 5. The coworker made a medication error last week.

1, 2, and 4

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What is an example(s) of legal safeguards for the nurse? Select all that apply. 1. The nurse confirms informed consent was give by the client to perform a procedure. 2. The health care provider is responsible for administration of a wrongly prescribed medication. 3. The nurse educates the client about what to expect during the hospital stay. 4. The nurse executes the health care provider's prescriptions without questioning them. 5. The nurse documents all client care in a timely manner. 6. The nurse claims management is responsible for inadequate staffing leading to negligence.

1, 3, and 5

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?

Assessment

Which activity is the clearest example of the evaluation step in the nursing process?

Checking the client's blood pressure 30 minutes after administering captopril Explanation: Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, whereas recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?

Document this assessment based on the client's behaviors.

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

Reflection

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply. 1. A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. 2. All plans of care are the same for clients with certain medical diagnoses. 3. Only the client is involved in outcome setting, not the family. 4. Outcomes can be short- and long-term. 5. Outcome setting allows for individualization of the plan of care.

1, 4, and 5

While walking down the hall, a nurse manager overhears a staff member telling a client, "If you don't stay in this chair and stop wandering, I'm going to tie you to it." The nurse manager pulls the staff member aside and discusses what was said. The nurse manager intervenes because the staff member's statement is which type of tort?

Assault Explanation: The staff member's statement reflects a threat of contact with another person without the person's consent. This is considered assault. Battery is an assault that is carried out and includes willful, angry, and violent or negligent touching of another's body or clothes (or anything attached to or held by that person). False imprisonment is the unjustified retention or prevention of the movement of another person without proper consent. This would apply if the staff member did in fact tie the client to the chair. Invasion of privacy involves the disclosure of information without the person's consent.

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case?

Breach of duty; failure to assess, intervene, or notify the health care provider regarding the client's condition.

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies?

Health care institution

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case?

The Good Samaritan law will provide legal immunity to the nurse.

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use?

Trial-and-error problem solving

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?

"I cannot give you that information due to client confidentiality."

A nurse is writing a letter to a U.S. congressman to support the promotion of health care issues. Which guidelines would ensure a properly written letter? Select all that apply. 1. The nurse should state the purpose of the letter briefly and clearly in the first paragraph. 2. The nurse should name the city and state where the nurse lives and votes. 3. The nurse should avoid using specific examples from the workplace to support the position. 4. The nurse should restate exactly what the legislator should do at the end of the letter. 5. The nurse should write a longer email and shorter letter. 6. The nurse should address the letter to as many legislators as possible.

1, 2, and 4

The nurse attorney provides an educational session to the nursing staff on acts of negligence. Which responses by the staff would indicate to the attorney that the staff can accurately identify acts of negligence? Select all that apply. 1. "I can be charged with negligence if I apply a heating pad to the client's skin and the client suffers a superficial or first-degree burn." 2. "I can be charged with negligence if I follow the policy for administering insulin and the client has a reaction to it." 3. "I can be charged with negligence if I am following the standards of care for my specialty, which is ambulatory nursing." 4. "When I am using a new piece of equipment for the first time, I must make sure I know how to properly operate it." 5. "I can be charged with negligence if I notify the health care practitioner about a change in a client's status but do not follow up or document.

1, 5

A nurse manager is developing a program for the unit staff to foster critical thinking. Which activity would the nurse manager implement to promote theoretical knowledge?

Encouraging staff to read current journal articles