PrepU Passpoint Coordinated Care
Which statement reflects appropriate documentation in the medical record of a hospitalized client?
"Client's skin is moist and cool." Explanation: Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.
While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response?
"I'm sorry, I can't disclose client information." Explanation: The nurse is bound by the rules of confidentiality and can't reveal any information about a client or treatment, and should state this fact to the neighbor. Suggesting that the neighbor call the client is inappropriate because the nurse is inadvertently disclosing information and acknowledging the client's presence at the clinic. Saying that the client is stable and doing well is a blatant violation of the client's right to absolute confidentiality.
A client that works as a pilot tells the nurse that they use illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide the nurse's interaction with the client, which is the nurse's best response?
"You could easily have an error in judgement and cause a serious accident." Explanation: Because the nurse's statement refers to those who could be harmed as a result of the pilot's drug use, the nurse's suggestion that the client should consider how an error in judgment could result in a serious accident reflects the principle of nonmaleficence (the obligation to do no harm). Telling the client that recreational drug use jeopardizes the client's health and decision-making ability addresses the personal danger of drug use, not the principle of nonmaleficence. Commenting that the pilot could test positive in a random drug test does not address any of the four basic ethical principles (autonomy, beneficence, nonmaleficence, and justice). Telling the client that there is a problem with their use of drugs to cope with stress reflects the principle of autonomy by addressing how the client's actions influence the rights of others.
A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's parent reports a plan to have his child declared legally incompetent. Which response by the nurse is most therapeutic?
"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." Explanation: The client is temporarily unable to make decisions about health care and safety. After receiving emergency care and treatment, the client will probably be able to safely manage daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting civil rights. A guardian doesn't assume financial responsibility.
A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN?
9-year-old child receiving subcutaneous insulin for diabetes mellitus Explanation: The unit manager should assign the LPN/VN to the child with diabetes mellitus. Because the client is receiving subcutaneous insulin rather than IV insulin, the diabetes is likely stable. Meningitis is an acute condition with the potential to progress into respiratory depression and seizures; 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; the child with this condition requires aggressive monitoring.
A nurse is caring for a school-age child who's dying of brain cancer. The parents have requested information about a do-not-resuscitate (DNR) order. Which of the following is the nurse's most appropriate response?
A DNR order does not mean withholding treatment while the child is alive. It involves not initiating treatment after the child has died. Explanation: Parents will likely have difficulty dealing with end-of-life decisions for their child, but they must be informed of all available treatment options. The health care team members need to educate family members regarding the possible choices, and encourage them to discuss their feelings and explore their wishes for their child. A DNR order does not mean withholding treatment while the child is alive. It involves not initiating treatment after the child has died. Parents are reminded that if a DNR order is chosen, they may revoke the order at any time. The health care providers should assure the family that their child will be cared for and comfort will be maintained regardless of the presence or absence of a DNR order.
The nurse is working on an ethics committee that is reviewing client-nurse interactions. Which nursing action indicates negligence?
A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue injury. Explanation: Negligence is the unintentional failure of a nurse to perform or not perform an act or behave in a way a reasonable nurse would not. Additionally, for a nursing action to be considered negligent, there must be client injury. A reasonable nurse would have removed the tourniquet after obtaining blood, therefore, the unintentional act harmed the client and constitutes negligence. Although the nurse failed to complete a fall risk assessment within an appropriate time frame, there was no client injury; therefore, it is not considered a negligent action. Crushing medication and giving it is intentional and may be within the facility's policy and therefore not negligence. Administering a generic drug instead of a brand-name drug per the pharmacist's orders constitutes no error.
A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order?
Ask the physician to prescribe a specific laxative. Explanation: The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug. The other options are incorrect because they put the nurse in the position of prescribing a medication and not following established professional standards for the administration of medication.
A nurse is caring for a morbidly obese client who has undergone surgery for weight loss. The client reports pain 8/10 despite morphine sulfate 1 mg/hour continuous infusion being administered via a patient-controlled analgesia (PCA) pump. Which action will best protect the nurse from issues of liability?
Contact the health care provider with a request for a change in PCA Explanation: State Boards of Nursing and the provincial or territorial nursing regulatory bodies set acceptable standards for nursing for a particular state or Canadian province or territory. Practicing within those guidelines will protect the nurse from liability. A nurse has a legal responsibility to address and manage a client's pain. The nurse would recognize that morphine 1 mg/hour continuous intravenous infusion may not provide adequate pain control in a morbidly obese client. The best option to avoid liability issues regarding pain control would be to contact the health care provider to request a change in analgesia for this client. Offering nonpharmacologic means of pain control is appropriate, but fails to address the need for a change in PCA. Adding a self-administered dose of morphine sulfate via PCA without a health care provider prescription would be outside the scope of practice for a registered nurse. Explaining to the client that pain is to be expected does nothing to meet the legal responsibility the nurse has to manage a client's pain and increases a nurse's risk of liability.
A client tells the visiting community health nurse that another client's name and phone number were seen on the call display after the previous day's nurse used the client's home phone. What should the nurse do in response to this conversation?
Discuss the matter with the other nurse, reminding the other nurse not to use the client's phone because it has a call display feature. Explanation: Leaving personal information in view of other people is a breach of confidentiality. The nurse should inform the other nurse of the incident. The other options are incorrect because they do not protect the client's privacy and do not address the behavior of the other nurse.
A client's family just completed a care conference with the health care team. The family has decided to withdraw treatment. What is the nurse's next step?
Document the decision in the client's electronic record. Explanation: After a decision has been made, the nurse should document the decision in the client's electronic record. This will alert additional members of the health care team. The client should not be transferred to a different floor. The pharmacy will receive notification from the EMR. Family members should communicate to others about the decision. The nurse should be caring for the client.
A nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls these oversights to the colleague's attention, but the colleague claims that standard precautions and gloves are unnecessary unless the client is known to have tested positive for the human immunodeficiency virus. Which action would be most appropriate for the nurse to take?
Document the problem in writing for the nurse manager. Explanation: The nurse who has observed the colleague's failure to use standard precautions has spoken to the colleague under the appropriate circumstances, and the colleague's comment indicates the need for further education. Therefore, the appropriate action is to bring the problem to the nurse manager's attention. Talking with other staff members about the situation would be unproductive because they do not have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice is not meeting standards.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.
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?
Influence of the extended family Explanation: 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 with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives?
Inform the client or legal guardian of his right to execute an advance directive. Explanation: The PSDA of 1991 requires all health care facilities to notify clients upon admission of their right to execute an advance directive. The facility's ethics committee can decide on a treatment plan if the client is unable to do so, and a durable power of attorney hasn't been appointed. Hospitals aren't required by law to respect individuals' moral rights; however, health care professionals should do so as part of their professional responsibility. Health care professionals are sometimes concerned that advance directives prevent treatment that might help the client. However, the hospital shouldn't advise clients not to execute an advance directive.
Which documentation is most important when preparing a preschool-age child for surgery?
Informed consent Explanation: Making sure that informed consent is documented is most important before surgery. Documenting vital signs and preoperative teaching and medication administration are also important but not as important as informed consent.
A nurse is caring for an 8-year-old female with multiple, chronic urinary tract infections. While the nurse helps the child's parent provide morning care, the child states, "My uncle doesn't clean me that way." The parent becomes visibly upset and gives the girl a stern warning not to discuss the matter. What is the priority action for the nurse?
Notify the nursing supervisor and the authorities of the possibility of abuse. Explanation: The nurse has the legal responsibility to report suspected abuse of a child or an older adult to the nursing supervisor and authorities. The nurse should have the experts continue with an investigation and not ask any more questions. If the nurse suspects abuse, the nurse is obligated to report the suspicion of abuse. The documentation of the event is important but not the priority.
A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take?
Notify the physician immediately to have the physician determine client competency. Explanation: Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.
A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first?
Obtain blood cultures. Explanation: All of the orders that the health care provider initiated are important but the nurse should obtain the blood culture before starting any other interventions—especially before starting the ampicillin. If the culture is obtained after a dose of ampicillin has been given, the results of the culture could be altered and unreliable.
A nurse caring for a client in the home learns from the client's spouse that the client refuses to take medication in the morning. The nurse suggests that the spouse crush and mix the pills in orange juice so the client will not know they are there. The nurse reports this recommendation to the team caring for the client so others can do the same. Which is the most appropriate response by the other nurses?
Offer to determine why the client is refusing the medication. Explanation: The best solution to the problem is to find out why the client is refusing the medication. Tricking or hiding medication in food is unethical and could constitute abuse. The other answers do not respect the client's right to choice. Discontinuing needed medications is not in the best interest of the client.
A nurse notices that a severely depressed client is crying and asks what's wrong. The client responds, "Well, it looks like my suspicions are about to be confirmed." When asked what that means, the client refuses to talk about the matter. The nurse later notices a letter from the client's spouse lying on the floor near the bed. The client is in session with the psychiatrist and the nurse believes the contents of the letter could offer clues about the client's depression. What is the nurse's best course of action?
Pick up the letter and place it on the client's bedside table. Explanation: One of the basic client rights is the right to send and receive unopened mail. Placing the letter on the client's bedside table is the professional response. Reading the letter is inappropriate and violates the client's rights. Asking the client if the nurse may read the letter is too direct and invasive and may alienate the client. The nurse might consider using indirect communication at a later time and invite the client to share the contents of the letter if comfortable doing so.
A nurse is caring for a client who has a brain tumor and increased intracranial pressure (ICP). Which nursing intervention should be included in the client's care?
Provide rest periods between nursing interventions. Explanation: Nursing interventions for a client with increased ICP should be spaced throughout the day to prevent further increase in ICP, which can occur with any type of stimulation. Coughing increases ICP by increasing intrathoracic pressure and reducing venous return. Keeping the head in midline and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Both sensory stimulation and noxious stimuli can increase ICP.
After a physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond?
Provide the information requested. Explanation: As part of the multidisciplinary team, the nurse is empowered to help the client better understand the process, as long as the nurse has an understanding of the treatment plan. The nurse shouldn't discourage the client from participating in the research study. Providing information about the clinical trial isn't beyond the scope of nursing practice. It isn't necessary for the information to come from the physician who originally presented it to the client.
A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first?
Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. Explanation: The nurse should return to the room to check the client's identification against the medication administration record. If there was an error, the nurse should then complete a variance report in accordance with facility policy and check the remaining medication before administering it to the second client. The client record shouldn't include documentation of a completed variance report. The nurse should inform the charge nurse of the error after confirming that an error has been made.
A nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What are the appropriate actions for the nurse to take? Select all that apply.
Speak to the charge nurse about the assignment. Document all concerns in writing about the assignment. Explanation: When a nurse feels unable to safely perform an assignment, the appropriate action is to speak to the nurse in charge. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice.
A nurse who's assigned the care of six clients is administering a tube feeding to a client when breakfast trays arrive. A client who needs assistance with meals helps herself to her tray and spills hot coffee on her chest and abdomen. How should the nurse intervene?
Stop administering the tube feeding and assist the client with changing her wet clothing, assess the burns, and notify the charge nurse. Explanation: The client who spilled the hot coffee needs immediate assistance. Therefore, the nurse should stop administering the tube feeding and attend to the other client immediately. The nurse should assist the client with removing the wet clothing. Then she should assess the burns and notify the charge nurse, who should report the incident to the physician and nursing supervisor. An incident report should also be completed according to facility policy. After the client is attended to, the nurse should resume feeding the other client through the feeding tube. Although it might appear that the client who spilled the coffee was impatient, the nurse shouldn't reprimand her for attempting to be independent. The nurse shouldn't request a replacement tray and remove the wet clothing without assessing the burns and notifying the appropriate staff members of the incident.
A newer nurse is assigned to care for several children with advanced cancer. The nurse finds the assignment extremely challenging due to a lack of experience and is considering requesting a different assignment. What is the best course of action by the nurse to resolve the situation?
Suggest a shared assignment with a senior staff nurse. Explanation: Suggesting a shared assignment shows collaboration and uses the experience and knowledge of colleagues. It would never be wise to continue with an assignment that was too difficult for the skill set and experience of the nurse. The notification to the nurse manager will not solve the issue but can bring about a dialogue. The nurse bringing reference materials may cause the clients to suspect problems, which can increase anxiety. Leaving the assignment by pretending to be ill does not allow for learning and client care.
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 action should the nurse take regarding informed consent?
Take the client to the operating room for surgery without informed consent. Explanation: 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.
The children of a 78-year-old client with a recent diagnosis of early-stage Alzheimer's disease are attempting to convince their parent to move into an assisted living facility, a move to which the client is vehemently opposed. Both the client and the children have expressed to the nurse how they are entrenched in their position. Which statement expresses a utilitarian approach to this dilemma?
The decision should be made in light of consequences. Explanation: Utilitarianism is the theory of ethics that weighs rightness and wrongness according to consequences and outcomes for all those who are affected. Utilitarianism prioritizes these consequences and outcomes over principles such as autonomy and justice, principles that underlie the other statements addressing the client's right to self-determination and fair distribution of benefits and burdens.
An 80-year-old client has an advance directive that states "do not keep alive by any heroic means." The client suffered a heart attack, and the family is requesting full code. Which nursing action taken by the nurse is correct?
Use only pain medication to keep the client comfortable. Explanation: Implementing full resuscitation at the family's request violates the client's rights. CPR is considered heroic and should not be implemented. Using pain medication to keep the client pain free and comfortable is humane and does not violate the client's autonomy. Transferring the client to the intensive care unit will involve intubation and other heroic measures.
Which statement demonstrates a safe practice for taking a telephone prescription from a health care provider?
Verify the prescription by reading it back to the health care provider. Explanation: Nurses may accept telephone prescriptions, but should do so only when absolutely necessary. To verify the information, the nurse must read back the prescription and clarify any questions about the prescription. Telephone prescriptions are acceptable in situations where a health care provider is not available and should be authenticated within 24 to 72 hours by the prescribing practitioner or another practitioner who is responsible for care of the client. Asking another nurse to witness the prescription by listening on the phone is not necessary and is not as effective as repeating the prescription back to the health care provider. Asking the health care provider to repeat the prescription three times does not verify that the nurse has transcribed the prescription correctly.
A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she sees that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do?
Voice her concerns about continuity of care with the charge nurse. Explanation: The nurse should voice her concerns about the need for continuity of care with the charge nurse. The nurse shouldn't independently change her assignment without the charge nurse's permission to do so. Just providing care for the newly assigned clients and visiting the former clients on breaks don't address the need for continuity of care.
The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated?
Wetness in the sterile cloth on top of the nonsterile table has been noted. Explanation: Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated.
A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes priority?
a child who develops a fever during a blood transfusion Explanation: A fever indicates an adverse reaction to the blood transfusion and requires immediate intervention. The post-surgical child is losing blood through the surgical incision, which also requires attention. However, managing the bleeding may take significant time. Between these two priorities, stopping the transfusion and beginning normal saline should be accomplished first and takes minimal time. Postponing stopping the blood to manage the bleeding from the post-op patient will cause potentially life threatening complications for the blood transfusion patient. The telephone call is important for medication changes and to prevent a delay in treatment. Airway management is also a high priority. At this point, the child is compensating with a reasonable oxygen saturation. In this scenario, the most critical situation is the blood transfusion reaction, which requires the quickest intervention to stop potential complications.
The licensed practical nurse (LPN) is caring for a group of clients on a medical-surgical floor. Which client should the nurse attend to first?
a client whose lower leg is red and swollen Explanation: The LPN should first attend to the client whose lower leg is red and swollen. This client may have deep vein thrombosis caused by immobility, which should be investigated further. An apical pulse rate of 80 beats/minute is within normal limits. The LPN should address the clients' concerns about going home and receiving the breakfast tray; however, those concerns don't take priority.
A client with terminal breast cancer is being cared for by a long-time friend who is a physician. The client has identified her sister as the agent in her healthcare power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should
abide by the wishes of the sister who holds the durable power of attorney. Explanation: A healthcare power of attorney transfers an individual's rights regarding healthcare decisions to the designated agent. It's within the sister's power to change the physician caring for the terminally ill client. The dismissed physician has no power to interfere with the wishes of the healthcare power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be?
administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management the priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions do not take priority over pain management.
A client informs the nurse that he is leaving the healthcare facility because he is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and few investigations are scheduled. Which is the most appropriate action by the nurse to prevent false imprisonment?
ask the client to sign release without medical approval Explanation: If a client wants to leave the healthcare facility, the nurse should ask him to sign a release stating that he or she left without medical approval. The nurse cannot restrain the client because doing so amounts to false imprisonment. Calling the physician is not an appropriate measure. Telling the client that he may not be able to access the healthcare facility again is an inappropriate response because healthcare is a right and the client can access it whenever necessary.
Each morning, a nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the nurse should have completed the tasks no matter what happened. Which leadership style is the nurse-manager exhibiting?
autocratic Explanation: An autocratic leader retains all authority and responsibility and is concerned primarily with completing tasks and meeting goals. The autocratic leader does not emphasize free thinking in the daily care of clients. The autocratic leader sets rules and expects all to follow them. A democratic leader is people-centered, allows greater individual participation in decision making, and maintains open communication. A permissive or laissez-faire leader denies responsibility and abdicates authority to the group.
A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing?
caring for the same child from admission to discharge Explanation: Primary care nursing requires that the primary nurse care for the same child (to whom the nurse is assigned) during a scheduled shift. The associate nurse is assigned to the child care assignment when the primary nurse has a day off or during the evening and night shifts. Caring for different children each shift doesn't promote continuity of care. Taking vital signs for every child on the floor is an example of team nursing, in which each member of the team is assigned one specific task for each child. The charge nurse may be directly involved in child care.
Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?
client with a compromised skin graft Explanation: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy is not used to improve the oxygenation status of a client with chronic obstructive pulmonary disease or pneumonia. This type of treatment would not encourage bone healing after a fracture.
A nurse is caring for a client who is well known in society. A person inquires about the medical details of the client, saying that they are a family member. The nurse reveals the requested information. Later, the nurse comes to know that the inquirer was not a family member. Which ethical rule of professional-client relationships has the nurse violated?
confidentiality Explanation: The nurse has violated the principle of confidentiality by revealing the client's personal medical information to a third person. Confidentiality is a professional duty and a legal obligation. What is documented in the client's record is accessible only to those providing care to that client. The nurse's action does not violate rules of veracity, fidelity, and privacy. Fidelity means being faithful to one's commitments and promises. Veracity means telling the truth which is essential to the integrity of the client-provider relationship.
The nurse is assisting with the development of a care plan for a postpartum client who had an uncomplicated vaginal birth of an 8-lb, 2-oz (3,693-g) neonate over an intact perineum 24 hours ago. While planning care for this client, the registered nurse collaborates with the licensed practical nurse to achieve which priority outcome in the next 8 hours?
encouraging the client to demonstrate an ability to breast-feed the neonate Explanation: With an uncomplicated vaginal birth, the average client will be hospitalized for 48 hours or less. By 24 hours postpartum, it's important for the client to start demonstrating the ability to care for her neonate. The first bowel movement occurs on average 2 to 3 days postpartum. The rubella vaccine is given, when indicated, on the day of discharge. This client delivered over an intact perineum, so a sitz bath isn't a priority.
A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?
enterostomal nurse Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.
During the planning step of the nursing process, the nurse
establishes short- and long-term goals. Explanation: During the planning step of the nursing process, the nurse establishes priorities and short- and long-term goals, projects measurable outcomes, and develops a care plan. The nurse determines the client's goal achievement during the evaluation step, writes statements about the client's health problem during the nursing diagnosis step, and gathers objective data during the assessment step.
A nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider?
incompatibility between the child's history and the injury Explanation: Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. For example, the child may have a skull fracture but the parents state that the child fell off of the sofa. The other criteria also may suggest child abuse but are less reliable indicators.
A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as
moxifloxacin 400 mg daily Explanation: Among the Joint Commission's list of "do not use" abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the Joint Commission recommends writing "daily" in the order.
A nurse is reviewing the interdisciplinary plan of care for a client experiencing hallucinations. Which intervention would the nurse most likely identify as being included in the plan?
providing a competing stimulus that distracts from the hallucinations Explanation: Providing a competing stimulus acknowledges the presence of the hallucinations and teaches the client ways to decrease their frequency. The other nursing actions support and maintain hallucination occurrence or deny its existence.
A nurse is caring for clients in a subacute unit. Which client care takes priority?
suctioning a tracheostomy client with oxygen saturation of 90% Explanation: Using Maslow's hierarchy of need, the priority is maintaining airway. If the airway is not maintained, the client can die of asphyxia. Changing a dressing and colostomy are necessary but not emergent. Administering pain medication is the next priority after airway.
After working multiple shifts in the psychiatric intensive care unit, a nurse is becoming more distant and, at times, even irritable. The best action for the nurse to take would be to:
talk with the charge nurse and seek support from peers on the unit. Explanation: Talking with the charge nurse and the nurse's own peers provides an opportunity for the nurse to express legitimate feelings and receive support and encouragement from others who understand. Although requesting vacation time may be helpful for the nurse in the short term, it isn't the best step to take. Requesting a less-demanding assignment is avoidant and doesn't address the nurse's feelings. Continuing to work without dealing with the feelings doesn't allow the nurse to provide the most therapeutic care to the clients. One of the most important factors in psychiatric nursing is self-knowledge.
Professional regulations and laws that govern nursing practice are in place for what reason?
to protect the safety of the public Explanation: Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice. The other options do not describe accurately the role and responsibility of the governing bodies and the regulations and laws of nursing.
A nurse is concerned about a client's ability to retain information during education sessions. Which of the following techniques would enhance the retention of material in presentations?
using repetition Explanation: Repetition is an effective means of reinforcing critical information and enhancing content retention. The other options will not increase the client's ability to retain information and may actually decrease concentration.