PassPoint MS Professional Behaviors/Professionalism ML6
A nurse's coworker tells the nurse, "I am not going to get this year's flu vaccination. Last year I felt sick right after I got it." What is the nurse's best response? A. "Reducing your own risk of getting influenza ultimately benefits your clients." B. "It is our responsibility as healthcare providers to keep vaccinations up to date." C. "If you could guarantee that you will not get influenza for a year, why would you not do it?" D. "I hope you change your mind. I am sure it was just coincidence that you did not feel well after getting it last year."
A Framing the issue in terms of benefiting clients is likely more effective than making a declaration about professional responsibility. Influenza vaccinations do not confer 100% protection against the disease.
A client who is taking olanzapine states he is being poisoned and refuses to take his scheduled medication. The nurse states, "If you don't take your medication, you'll be put into seclusion." The nurse's statement is an example of which legal concept? A. invasion of privacy B. assault C. malpractice D. battery
B The nurse's statement exemplifies assault, which is the threat of being touched in an offensive way without consent. Battery is touching another person without consent. Malpractice is care below the standard of care that results in injury. Invasion of privacy is a violation of a person's right to be left alone.
A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse? A. Encourage them to talk for 10 more minutes and then remind them that there are other tasks to perform on the unit. B. Encourage the family to identify their frustrations and fears. C. Explain that the unit is short staffed and that the nurses are doing the best they can. D. Call the nurse manager to speak with the couple.
B This response will assist the family in identifying their frustrations and fears so the nurse can work toward resolving their issues. It is inappropriate to tell the client about staffing-related issues or to give them a time limit for which they are able to express their concerns. The nurse manager may need be brought into the situation but first the nurse should try to work toward resolving the issues with the clients.
A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply. A. The nurse must have read the chart incorrectly. B. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. C. The nurse was correct to call a code blue. D. The physician was correct to stop resuscitation efforts. E. The code should have continued.
B, D By initiating a code blue, the nurse didn't follow the client's advance directive and DNR order. The physician was correct to follow the client's wishes and stop resuscitation efforts. The physician had the authority to stop the code.
A nurse on a labor and birth unit goes to the cafeteria for lunch with colleagues. One colleague begins talking about a newer staff member and says, "I heard that she does not have any labor and birth nursing experience." Which is the nurse's most appropriate action? A. Ask how the colleague knows this information. B. Ignore the comment because it is not considered harmful. C. Discuss the colleague's behavior in private. E. Confront the colleague immediately to prevent causing additional harm.
C This behavior is unprofessional and breaches confidentiality as per the American Nurses Association (Canadian Nurses' Association) Code of Ethics. The nurse is obligated to approach the colleague and discuss inappropriate behaviors. Therefore, it is inappropriate to ignore the comment. Discussing this in private demonstrates professional conduct rather than confronting the colleague immediately. It is inappropriate to ask how the colleague knows this information because doing so would contribute to the unprofessional behavior.
A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond? A. Stop attending this support group. B. Pretend not to know the client. C. Let the client establish the rules. D. Discuss this to define the relationship.
D Social media and self-help groups can contribute to blurred boundaries between personal and professional relationships. The nurse should take the lead to discuss boundaries with the client. This means that the relationship needs to be defined. Generally letting the client do this fails as the client does not understand the conflict and responds positively to having contact with the nurse outside of the professional setting. Pretending not to know the client can be hurtful, while leaving the group can be detrimental to the nurse.
A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: A. ensuring that the suspected child abuse is reported to local authorities. B. reporting the suspicions to the hospital's chief of pediatric services. C. contacting the infant's next of kin to begin discharge planning. D. contacting the local children's protective service office with an anonymous tip.
A Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to the next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.
While listening to an audio recording of a report at shift change, one of the other team members remarks, "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation? A. Ask the team member what the purpose was in sharing the information. B. Ask the team member to be quiet. C. Ignore the comment. D. Include the information in the report for the next shift.
A The assigned nurse should determine if the comment has any relevance to the care of this client. Ignoring the comment or asking the team member to be quiet does not help determine if the comment was appropriate. Only information that has therapeutic value should be shared with other team members.
The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. When should the nurse discuss the care with the UAP? A. The UAP ambulates the client. B. The UAP massages the client's legs. C. The UAP asks the client to wear elasticized stockings. D. The UAP assists the client perform range-of-motion exercises in bed.
B Massaging the legs postoperatively is contraindicated because it may dislodge small clots of blood, if present, and cause even more serious problems. Ambulation, elasticized stockings, and moving the legs in bed all help reduce the risk for thrombophlebitis.
A registered nurse (RN) is assigning care on the oncology unit and assigns a client with Kaposi sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). The UAP does not want to care for this client. How should the nurse respond? A. "I will review blood and body fluid precautions with you." B. "You seem worried about this assignment." C. "I will help you take care of this client so you are confident with the care." D. "I will assign this client to another nurse."
B The RN assigning care should first give the UAP the opportunity to explore concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care.
The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent? A. Patterns of verbal communication B. Influence of the extended family C. Religious beliefs D. Gender identity
B The influence of the extended family is the cultural factor that is causing the nurse's dilemma. It is common for English-speaking women to defer to an extended family member in both formal and informal decision-making situations. Language barriers may present challenges at times, but translators may be involved in particular when discussing health-related decisions to ensure understanding.
A client is complaining to other clients about not being allowed by staff to keep food in their room. What action should the nurse take? A. Ignore the client's behavior. B. Allow snacks to be kept in the client's room. C. Set limits on the behavior. D. Reprimand the client.
C The nurse needs to set limits on the client's manipulative behavior to help the client control dysfunctional behavior. The manipulative client bends rules to have needs met without regard for rules or the needs or rights of others. A consistent approach by the staff is necessary to decrease manipulation. Ignoring the client's behavior reinforces or promotes the continuation of the client's manipulative behavior. Reprimanding the client may be perceived as a threat, resulting in aggressive behavior. Allowing the client to keep a snack in the client's room reinforces the dysfunctional behavior.
After the nurse informs the surgeon that a chest tube is malfunctioning, the health care provider asks the nurse to reposition the tube and obtain a chest radiograph. What should the nurse do? A. Report the surgeon to the nursing supervisor. B. Inform the surgeon this is not within the scope of nursing practice. C. Report the surgeon to the Ethics Committee. D. Follow the prescription as requested by the surgeon.
B Initially, the nurse needs to inform the surgeon that the task is outside the scope of nursing practice. If the surgeon still requests the activity, the nurse should refuse to perform the task and should follow the chain of communication for reporting unsafe practices according to the facility's policy. The nurse must not comply with any prescription that goes beyond the scope of nursing practice.
A nurse meets a 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? A. Share the feedback with the nursing colleague directly. B. Send the colleague an anonymous card. C. It is a breach of confidentiality to share this information with the colleague. D. Post accolades to the nurse at the nurses' station.
A 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 nurse assists a student nurse conducting an interview with the family of a 4-year-old child who is often disruptive in preschool class, is difficult to engage, and rarely speaks. Which question, if asked by the student, would require intervention by the nurse? A. "Has your child received all their childhood immunizations? There is evidence that childhood immunizations play a role in the development of autism." B. "How do you respond if they disobey or act out at home? If your techniques help stop or prevent negative behavior, perhaps the teachers can try similar measures at school." C. "Has your child been evaluated by a pediatrician? They seem to have some behaviors that are atypical for a child of their age." D. "How does your child behave at home? If you do not see acting-out behavior at home, part of their problem may be dealing with new situations such as school."
A The child's behavior appears to fit the criteria for autism, but suggesting the child's immunizations are causative is inaccurate according to recent research and dangerous because it could convince the parent to forego future immunizations.Suggesting a full evaluation by a health care provider is appropriate, especially since symptoms could result from other illnesses or conditions. Inquiring about the child's behavior at home and the parents' discipline techniques would give the nurse a better idea of the home environment and could help determine whether this is a problem confined to the school setting or one that also occurs at home. Asking for the parents' input regarding discipline demonstrates a desire to involve them in problem-solving.
The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse? A. Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan. B. Complete an incident report on the previous shift for allowing the fall, and then reassess the client's fall-risk level. C. Assist the client to a comfortable position on the floor, and ensure the call light is in reach. Place a fall-risk alert sign outside the client's room, and then notify the next of kin. D. Move the client to a safe position, and modify environmental factors that could have contributed to the fall. Documentation is unnecessary as no injuries occurred.
A The nurse should notify the health care provider, then document the facts related to the fall, such as the location of the fall, health care provider notification, injury (if any), and necessary follow-up or changes in the care plan that occurred as a result of the fall. If an injury was present the client should remain where the fall occurred; however, if no injuries are noted the client should be assisted off the floor. The nurse should not include information that places blame on other health care members. The fall must be reported even if the client does not suffer an injury. Documentation of the incident in the client's chart is required.
A nurse observes another nurse making social plans with a client and disclosing information of a personal nature. What would the observing nurse do in this situation? A. Report the observation to the nurse manager. B. Discuss the observation directly with the nurse. C. Let coworkers know what is going on to have witnesses. D. Find out whether the nurse meets with other clients socially as well.
B Planning to meet a client socially and disclosing personal information could blur the boundaries of the therapeutic relationship, which may result in an unhealthy outcome for the client. The observing nurse should take the nurse aside and point out that this behavior is inappropriate and not in the client's best interest. Sharing the observation with coworkers is gossiping and does not address the issue. As a professional, the nurse has an obligation to help educate the other nurse. It is possible a reminder about professional boundaries will resolve the issue without requiring involvement of the nurse manager. Regardless if the nurse has met with other clients or not, this particular instance should be dealt with by directly discussing the concerns with the nurse.
The community nurse works with the family to answer their questions on infant care. The nurse would like to maintain therapeutic boundaries within the therapeutic relationship. Which of the following is the best way to maintain boundaries? A. The nurse arrives on time and fulfills the client's needs. B. The nurse does not disclose her home address or accept the invitation to stay for lunch. C. The nurse keeps the client's records secure when records are out of the office. D. The nurse communicates with the client via telephone.
B The nurse demonstrates her professional boundaries by not disclosing personal identifiable information or accepting a meal. Keeping records secure maintains confidentiality. The nurse builds trust and rapport by coming on time and fulfilling needs. Communicating via telephone maintains professional communication.
A new nurse is asked to present a case study during interdisciplinary rounds on a client who has compartment syndrome from a leg injury. The new nurse is uncomfortable with public speaking. Which action(s) by the new nurse is appropriate? Select all that apply. A. Ask to attend the rounds instead of presenting. B. Research the condition, and present what was learned. C. Review the client's chart to obtain assessment findings and treatment. D. Suggest that a more experienced nurse be selected to present this case study. E. Approach the unit manager and ask to be excused from presenting.
B, C This is an opportunity for new learning about a complication that pertains to the client and an important safety consideration when assessing and performing care measures. Presenting this case would also provide a professional growth opportunity. As a new professional on a unit, it is important to go beyond one's normal comfort zone. Attending rounds will be a learning experience, but not a challenging growth experience. Deferring to a more experienced nurse or approaching the nurse manager demonstrates avoidance of growth opportunities and failure to confront insecurities.
Which action performed by a nurse will increase the risk of liability? Select all that apply. A. witnessing a client sign a consent for an ordered medical procedure B. assisting a client on ordered bed rest to walk to the toilet C. providing information to a caller about a client's diagnosis and treatment D. asking unlicensed assistive personnel to assess a client's wound E. withholding a medication to clarify the ordered dosage
B, C, D Nursing standards of practice are stated within the nurse practice act of each state, territory, or province. These standards include scope of practice, delegation, professional ethics, and code of conduct. A nurse increases the risk of professional liability when performing activities outside of these standards. A nurse may not delegate a nursing task to a person, such as unlicensed assistive personnel, who does not have the proper training or skills to perform the task. The nurse should not act against physician orders without a professionally based reason, such as clarifying an order. Professional ethics requires protection of client privacy. Personal health information should not be provided to a caller without the client's consent.
A client diagnosed with cancer tells the nurse about wanting to stop treatment and die at home. The healthcare team suggests another round of chemotherapy. What statement by the nurse to the healthcare team best reflects client advocacy? A. "I believe that the client has something to offer to the treatment plan." B. "Can we discuss treatment options for the client other than chemotherapy?" C. "The client has expressed not wanting to pursue additional treatment." D. "I think chemotherapy may be more harmful for the client than no treatment."
C The nurse acts as an advocate by directly discussing the client's wishes with the team. The nurse needs to be an advocate, especially after learning earlier about the client's desires. Sharing the client's input is part of advocacy, but disclosure of the client's wishes to go home must be explored. Questioning the team's plan is not as direct a form of advocacy as pointing out that the client wishes to discontinue treatment. The nurse may open the conversation with other options, but the question does not address the client's wishes.
The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client's maternity clothes and baby furniture on the weekend. What is the preceptor's most appropriate action? A. Ask the client and student who initiated the idea for these arrangements. B. Immediately report the incident to the student's professor. C. Discuss the situation with the nursing student after the visit has ended. D. Ensure that this is a mutually agreed upon decision.
C The nurse has a professional responsibility to discuss this situation with the nursing student in private. The student needs to know that these actions are insensitive to the grieving parents and are unprofessional regardless of whether the client has agreed to it or even initiated the idea. These student actions do not value therapeutic boundaries between health care providers and their clients in the community. It may be appropriate to discuss it with the contact person from the student's academic institution; however, the first action should be to discuss it with the student in private.
A client is admitted with a diagnosis of schizophrenia. The client is paranoid and the student nurse asks the charge nurse about the approach to take with the client. The client has been exhibiting hostility and isolation. Which response by the student indicates understanding of the correct approach toward this client? A. Tell the client that if they do not comply with the rules, you will inform the doctor. B. Inform the client that they are unwell and you will assist them. C. Greet the client by gently touching their arm, and telling the client they can trust you. D. Respect the client's need for personal space and avoid physical contact with the client.
D A newly admitted client who is paranoid needs to have a sense of trust before the nurse attempts to touch the client. Touch is not therapeutic with someone who is suspicious. Using statements that imply the client is unwell or that potentially contain veiled threats will only increase the client's anxiety and lead to increased potential for hostility and anger.
The client with a lumbar laminectomy asks to be turned onto their side. How should the nurse assist the client? A. Turn the client's shoulders first, followed by the hips and legs. B. Ask the client to help by using an overhead trapeze to turn. C. Inform the client that because of the laminectomy, it is possible to only lie supine. D. Get another nurse to help logroll the client into position.
D After a laminectomy, the client's spine must be maintained in proper alignment. The client may be turned to the side by logrolling in one unit while keeping the back straight. It takes at least two people to perform this procedure correctly. Reaching up and using the trapeze will put stress on the operative area and cause the spinal column to twist. Such motions interfere with healing and can cause pain. Turning the shoulders and then the hips will cause the spine to rotate, which is contraindicated in the immediate postoperative period. Clients who have had a laminectomy should be assisted to side-lying positions to take pressure off the sacral area and stimulate circulation; however, position changes must be done so that the back stays in straight or neutral alignment.
A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. The LPN walks into the room and hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do? A. Do nothing because the client has been taking the medication for a long time. B. Allow the nursing assistant to administer this dose and tell the LPN later that it's the LPN's responsibility to administer the medication. C. Take the medication from the nursing assistant and administer it. D. Remind the LPN that it is the LPN's duty to administer the medications.
D The RN should intervene immediately by reminding the LPN that it's the responsibility of the LPN to administer the medications. The RN should reinforce to the LPN that medication administration is beyond the scope of practice for a nursing assistant, and that allowing the nursing assistant to administer medications could lead to client injury. Although the client has been taking the medication for a long time, the responsibility for medication administration lies with the RN and LPN, not the nursing assistant. It's important for the nurse to intervene at the time of the incident to prevent injury. The registered nurse shouldn't administer the medication because the RN didn't prepare the medication for administration.
A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation? A. Tell the charge nurse to be more specific about what is meant. B. Tell the charge nurse that the statement is hurtful. C. The new nurse should discuss feelings with a coworker in order to vent. D. Ask for a private meeting to explore the charge nurse's concerns in detail.
D The charge nurse's statement is vague; the priority issue is to gather information about what was meant. Meeting privately with the charge nurse is one way to diffuse tension in a nonthreatening manner and gather information that might have professional value for the nurse. Stating that the nurse felt hurt immediately focuses on subjective issues rather than objective concerns. Professional respect dictates inquiring about what the charge nurse meant, rather than telling the charge nurse to be more specific. Discussing the situation with a coworker may make the nurse feel better but doesn't address the issue at hand.
A client has been taking 30 mg of duloxetine hydrochloride twice daily for 2 months because of depression and vague aches and pains. While interacting with the nurse, the client discloses a pattern of drinking a 6-pack of beer daily for the past 10 years to help with sleep. What should the nurse do first? A. Refer the client to the concurrent disorders program at the clinic. B. Share the information at the next interdisciplinary treatment conference. C. Teach the client relaxation exercises to perform before bedtime. D. Report the client's beer consumption to the health care provider (HCP).
D The nurse should report the client's beer consumption to the HCP. Duloxetine should not be administered to a client with renal or hepatic insufficiency because the medication can elevate liver enzymes and, together with substantial alcohol use, can cause liver injury. Referring the client to the concurrent diagnosis program, sharing information at the next interdisciplinary treatment conference, and teaching the client relaxation exercises are helpful interventions for the nurse to implement. However, reporting the findings to the HCP is most important.
The nurse manager is holding a meeting with the nursing team to discuss management's decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening "to take this decision further." To defuse this situation, which would be the best step for the nurse manager to take? A. Tell the nurse who is acting out to settle down and to act professionally. B. Ask the rest of the staff if they also feel the same way. C. Suspend the nurse who is acting out for the inappropriate behavior. D. Call a break in the meeting and talk to the nurse in a private place.
D When an individual is verbally acting out and others are present, it is advisable to isolate the individual by either removing the individual from the audience or removing the audience. Doing this gives the person an opportunity to regain control of rational thinking without embarrassment in front of peers. It is not appropriate to initiate a suspension in public. By taking the person aside, it also keeps the audience from encouraging or coaching the acting-out individual and further escalating the situation. Asking the nurse to settle down and act professionally is not enough in this escalating circumstance.
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should A. give the client privacy during meals. B. stay with the client and encourage them to eat. C. fill out the menu for the client. D. help the client fill out their menu.
B Staying with the client and encouraging them to feed themself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.
A nurse finds that a colleague is intoxicated while on duty. What appropriate action would the nurse take? A. advise the colleague to go home B. ask another nurse if the colleague appears intoxicated C. inform the nursing supervisor D. ask the colleague if he or she is intoxicated
C When a colleague is intoxicated while on duty, the nurse should immediately inform the nursing supervisor, who may take necessary action. It would be an irresponsible action if the nurse tells the colleague to go home. Confronting the colleague by asking if he or she is intoxicated may result in denials and an attempt to avoid any repercussions. The nurse should not involve other staff members to protect the privacy of the colleague. Only the nursing supervisor needs to be made aware of the situation.
A group of nursing students are reviewing current nursing codes of ethics. Such a code is important in the nursing profession because: A. nurses are highly vulnerable to criminal and civil prosecution in the course of their work B. nurses interact with clients and families from diverse cultural and religious backgrounds C. nurses are responsible for carrying out actions that have been ordered by other individuals D. nursing practice involves numerous interactions between laws and individual values
D A code of ethics is necessary to guide nurses' conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.
A nurse is caring for a client with a central venous catheter who needs a dressing change. The nurse is uncertain about performing the procedure. What action will be most appropriate for the nurse to do first? A. Perform the dressing change as best as possible. B. Explain concerns about uncertainty to the client during the procedure. C. Have the nurse on the next shift complete the procedure. D. Review the facility's procedure for the steps to complete.
D The nurse should apply independent problem-solving and clinical reasoning as a first action. This would include reviewing the policy and procedure. It is likely still necessary for the nurse to collaborate with a colleague or manager, but independent problem-solving should be applied as an initial action. Performing the procedure when uncertainty could lead to client injury and sharing the uncertainty with the client is inappropriate.
The nurse is caring for an expectant mother who asks how decisions are made if complications place both the mother and fetus at risk. What ethical principle will the nurse cite when responding to the client's question? A. justice B. jurisprudence C. autonomy D. nonmaleficence
C The principle of autonomy informs decisions when conflicts arise between maternal and fetal rights. The woman has the right to choose for herself what she believes to be in her best interest versus the well-being of the fetus. This is the concept of self-determination, of being in charge of one's person rather than another person determining what behavior or decision represents justice. Nonmaleficence refers to doing no harm. The client has the right to make choices that align with her belief system. Jurisprudence is the actual theory or study of law.
The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm? A. Permit the mothers and their neonates to continue sleeping. B. Do nothing because it's most likely a fire drill. C. Immediately evacuate the unit. D. Close all of the doors on the unit.
D The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.
A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation? A. Insist that the officers stay in the room at all times. B. Ask one of the officers to remove the handcuffs. C. Perform morning care while the client is handcuffed. D. Ask another nurse to come into the room.
A A correctional officer should be with the client at all times. To protect the safety of the nurse and the client, the nurse should refuse to administer care without an officer present. The other options put the nurse and the client at risk.
A client with a history of pancreatic cancer is revived following cardiac arrest but is determined to have suffered brain death. The family tells the nurse they want to donate any usable body organs so their loved one can live on in others. Which action by the nurse is appropriate? A. Check the driver's license for a donor sticker to authorize organ donation. B. Call the local organ procurement representative to meet with them. C. Tell the family that the client is not a candidate for organ donation. D. Have the physician pronounce the client dead before taking the organs.
B An organ procurement organization representative is the best person to discuss organ donation with the family. Not all clients are candidates for organ donation for transplantation. People who have active cancer or systemic illnesses such as hepatitis or HIV cannot donate for transplantation, but their organs may be donated for research. The client and the organs will be evaluated by transplant specialists to determine the best use of the organs.
A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse? A. Notify the health care provider and social services. B. Inform the charge nurse of the family's concerns. C. Complete grievance paperwork for the family and hand it to them to submit. D. Explain to the client's family the previous nurse's actions were accidental.
B The nurse should follow the facility's policy and chain of command for handling complaints, which commonly begins with the charge nurse. The nurse should not complete grievance paperwork for the family. Additionally, the nurse should avoid trying to handle a problem involving another employee because doing so will only aggravate the issue. Notifying the health care provider of these issues is unnecessary. The nurse should not side with the family or with the other nurse.
An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination? A. Keep the client's friends (who are waiting in the lounge area) informed of her medical condition. B. Keep the suspected attacker away from the examination room. C. Have a female health care worker present. D. Leave the door open.
C A female health care provider should be present to observe an examination performed by a male health care provider. Leaving the door open and informing the client's friends about her condition violates her right to privacy and confidentiality. Although the suspected attacker should be kept away from the examination room, having a female health care worker present during the examination best protects the girl's rights.
A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse? A. Call the supervisor and report the officer's decision to keep the handcuffs on. B. Ask the physician for an order to remove the handcuffs. C. Continue to assess the client, allowing the officer to assume responsibility for the handcuffs. D. Refuse to provide care while the client is handcuffed to the stretcher.
C In this situation, the police officer has applied the restraint and has taken responsibility for the restraint. The nurse should assess the client for any potential complication from the handcuffs, document the assessment, and provide care to the client as usual. The other options are incorrect because the police officer has assumed responsibility for the restraint. It is unlikely that a physician would order the restraint to be removed against the officer's recommendation, and if the restraints are in place and the officer is present, the nurse can provide care to the client.
A client is diagnosed with Crohn's disease after undergoing two weeks of testing. The client's employer calls the medical-surgical floor requesting to speak with the nurse manager. The employer expresses concern for the client and requests information regarding the client's diagnosis for insurance purposes. Which response by the nurse is best? A. "You will need to speak with the client's healthcare provider regarding a medical diagnosis." B. "I'm unable to share information over the phone, so please visit the unit in person." C. "I appreciate your concern, but I can't give out any information." D. "It will be important to have this information to make certain the client has insurance coverage."
C The nurse and the healthcare provider may not release any confidential information to unauthorized individuals such as the client's employer. Sharing information with the employer or asking them to come in to discuss the issue both breach client confidentiality. The nurse should acknowledge the employer's concern and politely explain that no information may be shared.
