questions 3
A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an IV of D5 NS + 20 meq KCL/L running at 60 mL/h. Vital signs are a temperature of 100.4° F (38° C), heart rate of 120 bpm, respiratory rate of 28 breaths/min, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for: rectal diazepam. IV lorazepam. rectal acetaminophen. IV fosphenytoin.
IV lorazepam. Explanation: IV lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines act to potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter; stopping seizure activity. If an IV is not available, rectal diazepam is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.
The nurse is caring for a client admitted to a medical surgical unit. Which of the following situations would indicate a professional nurse's boundary violation? Select all that apply. Sharing a personal experience with a client that is very similar to the situation the client is experiencing Speaking to the client's family about a diagnosis without permission from the client Being concerned about a client's welfare and seeking ways to protect them Having well-intentioned behaviors that detract from achievable health outcomes for clients Reminding a client who has dementia that certain sexual touch behaviors are not acceptable
Sharing a personal experience with a client that is very similar to the situation the client is experiencing Speaking to the client's family about a diagnosis without permission from the client Having well-intentioned behaviors that detract from achievable health outcomes for clients Explanation: Professional boundaries focus on the provision of professional care that assists clients in achieving health outcomes. When the professional nurse becomes overinvolved in care, then it may affect those outcomes. Sharing a personal experience with a client that is very similar to the situation the client is experiencing is not appropriate because it places the focus on the nurse, not the client. Speaking to a client's family without permission violates confidentiality. Being concerned about a client's welfare and seeking ways to protect them and reminding a client who has dementia that certain sexual touch behaviors are not acceptable would not compromise professional boundaries.
The nurse is discussing entry level for professional nursing practices. Which of the following is the most accurate statement by the nurse? "ADN programs are the recommended entry level by national nursing organizations." "BSN is the recommended entry level by national nursing organization." "National nursing organizations are promoting diploma nursing." "National nursing organizations are eliminating accelerated programs."
"BSN is the recommended entry level by national nursing organization." Explanation: National nursing organizations are recommending that the entry level for professional practice be at the baccalaureate level. They are not eliminating accelerated programs for graduates of non-nursing disciplines.
An anxious client asks the nurse for the results of recent blood work and wants to know what the results mean. Which of the following responses by the nurse is the most appropriate? "Let me get your chart so that I can give you the results and tell you about them." "I understand your concern. I'll call the physician to review the results with you." "Don't worry. If anything were wrong, the physician would have told you." "I can't tell you the exact results, but I have seen them and they are okay."
"I understand your concern. I'll call the physician to review the results with you." Explanation: It is not within the nurse's scope of practice to provide clients with diagnoses based on laboratory results. The nurse should advocate for the client to receive the results from the physician and facilitate that discussion. The other options are incorrect because the nurse is providing information that the nurse is not permitted to release. Stating that the client should "not worry" will not address the client's anxiety about receiving the results (and interpretation) of the lab work.
Forty-eight hours after undergoing a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. Assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with a recommendation for: A dose of morphine. A fluid bolus of normal saline. A computerized tomography scan. A dose of furosemide.
A computerized tomography scan. Explanation: The infant is exhibiting signs and symptoms of increased intracranial pressure (ICP) caused by a shunt malfunction. A CT scan, shunt series X-ray, and tapping the shunt are performed to diagnose a shunt malfunction. Irritability results from the increased ICP, not postoperative pain. The infant has increased ICP; a fluid bolus will further increase it. The increased ICP is caused by a shunt malfunction and will not be relieved by furosemide. Surgical intervention is necessary to correct a shunt malfunction.
A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation? Advise the nurse that he/she can be accused of battery. Inform the nurse that he/she can be accused of negligence. Ask the nurse if this is acceptable practice for this unit. Notify the licensing body of the nurse's behavior.
Advise the nurse that he/she can be accused of battery. Explanation: Battery is defined as an intentional and wrongful physical contact with a person that entails an injury or offensive touching. The other options are not correct because they do not describe the nurse's behavior.
Which organization has established standards that help the nurse determine which clinical actions fall in the scope of nursing practice? American Nurses Association National League for Nursing International Council of Nurses State Board of Nursing
American Nurses Association Explanation: The American Nurses Association (ANA) has established standards of clinical nursing practice that define the specific and unique activities of nurses. Standards serve as protection for the nurse, the patient, and the institution where healthcare is given. The other organizations provide valuable services that differ from those of ANA.
Which of the following is the best example of the nurse in the role of teacher/educator? Assessing if the client is able to perform a dressing change Teaching a first grader to read Communicating discharge status to home care agency Conducting research on dressing changes
Assessing if the client is able to perform a dressing change Explanation: When in the role of teacher/educator, the nurse uses communication skills to assess, implement, and evaluate teaching plans to meet the learning needs of clients and their families. The nurse assessing if a client is able to perform a dressing change is assessing for the need for education on how to perform the dressing change. Teaching a first grader to read is an example of the nurse teaching, the teaching of children to read is not within the scope of nursing practice. Communication of discharge status is an example of the nurse as a communicator, and conduction of research is an example of the role of the nurse as a researcher.
Which of the following statements is NOT true about performance appraisal? A Informing the staff about the specific impressions of their work help improve their performance. B A verbal appraisal is an acceptable substitute for a written report C Patients are the best source of information regarding personnel appraisal. DThe outcome of performance appraisal rests primarily with the staff.
C The patient can be a source of information about the performance of the staff but it is never the best source. Directly observing the staff is the best source of information for personnel appraisal.
Nursing students are reviewing information about expanded nursing roles. They demonstrate understanding of the information when they identify which of the following as roles of an advanced practice nurse? Select all that apply. Certified nurse-midwife Certified critical care nurse Nurse practitioner Clinical nurse specialist Certified registered nurse anesthetist Certified medical-surgical nurse
Certified nurse-midwife Nurse practitioner Clinical nurse specialist Certified registered nurse anesthetist Explanation: Advanced practice nurses are nurses with advanced specialized education, usually at the graduate level. They include certified nurse midwives, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Certified critical care nurses and certified medical-surgical nurses have passed the certification examination but are not routinely considered advanced practice nurses.
performance appraisal consists of all the following activities EXCEPT: A Setting specific standards and activities for individual performance. B Using agency standards as a guide. C Determine areas of strength and weaknesses D Focusing activity on the correction of identified behavior.
D Performance appraisal deal with both positive and negative performance; is not meant to be a fault-finding activity
A nurse can improve his or her skill with time management by doing which of the following? Allowing the flow of the day to control how time is managed Setting priorities without involving clients or their families Starting each day as a new day without considering the previous day Evaluating success with accomplishment of goals in client care
Evaluating success with accomplishment of goals in client care Explanation: Time management is a skill that can be improved for nurses by taking time during the day to evaluate whether goals have been accomplished, and setting new priorities based on this. Goals and priorities should be established at the beginning of each day, and clients and their families should be involved in this. At the end of the day, a nurse should look back and determine what has and has not been accomplished; this helps to set a time line for the next day. If a timeline is not set each day, then the nurse will allow the flow of the day to control the day, rather than having a plan for what needs to be accomplished.
A nurse leader is planning to change the scheduling process in order to improve staffing on the unit. Which of the following would be the next step in implementing a change? Explore the pros and cons of potential scheduling models. Describe to the staff how the change will be implemented. Develop a timetable for making the change to a new system. Select a group of nurses to help champion the change process.
Explore the pros and cons of potential scheduling models. Explanation: Before a nurse leader can begin planning the process of change, a selection of a new system by fully exploring different models should be completed. Once a selection is made, the process for the change can begin by describing how change will be implemented with the timetable that is developed and enlisting support from the staff who will champion the cause.
An inmate 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? Perform morning care while the client is handcuffed. Insist that the officers stay in the room at all times. Ask another nurse to accompany the nurse into the room. Ask one of the officers to remove the handcuffs.
Insist that the officers stay in the room at all times. Explanation: A correctional officer should be with the inmate/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.
The nurse discussing the importance of professional nursing organizations setting standards should include which of the following statements? It helps identify nursing as a profession. It helps to identify nurses. It sets the standard for nursing research. It helps regulate nursing licensure.
It helps identify nursing as a profession. Explanation: Professional nursing organizations that set standards for nursing helps nursing meet the defining criteria for a profession. However, they do not regulate nursing practice, set standards for nursing research, or help to identify nurses.
One major requirement of a nursing diagnosis is that it focuses on a problem that is Established by the physician Based on the client's pathophysiology Legally treatable by registered nurses Included within the diagnosis-related group
Legally treatable by registered nurses Explanation: Registered nurses are educated and licensed to make nursing diagnoses. As such, they have a duty to identify and plan care for clients based on them.
Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next? No action is needed at this time because the drug level is normal. Contact the physician because these levels are elevated and may require a change in dosage. Assess client compliance with the prescribed medication regimen because these values are below therapeutic levels. Ask the laboratory to run the test again because these are critical values.
No action is needed at this time because the drug level is normal. Explanation: Normal therapeutic serum phenytoin level ranges from 10 to 20 mcg/ml. No nursing action is needed at this time.
Which statement is a guideline to help nurses protect themselves from liability? Follow all physician's orders. Do what the client desires even though the nurse may disagree. Practice within the scope of the nursing standards of practice.. Obtain malpractice insurance.
Practice within the scope of the nursing standards of practice.. 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. The nurse shouldn't follow all physician's orders because physicians may not be aware of guidelines for nurses and may delegate inappropriate treatment or practice for the nurse. The client doesn't know standards of care and isn't responsible for the nurse's actions. Insurance won't prevent a liability suit, it will only assist the nurse if a suit should be filed.
The registered nurse (RN) has received orders to perform an unsafe practice on a client. The RN voices concern with the physician who gave the order, but the physician refuses to change the order. Whom should the nurse consult next regarding the order? The client The charge nurse The nurse manager The licensed practice nurse (LPN)
The charge nurse Explanation: The RN should follow the proper channels for communication and consult the next direct supervisor. The next direct supervisor would be the charge nurse and then the nurse manager. The client and the LPN should not be consulted.
The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The physician asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent? Skilled communication Effective decision making True collaboration Appropriate staffing
True collaboration Explanation: True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses and between nurses and other health team member. Skilled communication requires health team members to communicate in a non-intimidating manner with colleagues, allowing all voices to be heard regarding a matter. Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations.
A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because: Nurses are highly vulnerable to criminal and civil prosecution in the course of their work. Nurses interact with clients and families from diverse cultural and religious backgrounds. Nursing practice involves numerous interactions between laws and individual values. Nurses are responsible for carrying out actions that have been ordered by other individuals.
Nursing practice involves numerous interactions between laws and individual values. Explanation: 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 nursing student asks the clinical instructor to explain the difference between quality improvement and quality assurance. Which response by the clinical instructor is appropriate? "Quality improvement focuses on organization structure and individuals." "Quality assurance promotes empowerment and collaboration." "Quality improvement focuses on processes, data, and statistical thinking." "Quality assurance is concerned with patient satisfaction."
"Quality improvement focuses on processes, data, and statistical thinking." Explanation: Quality improvement focuses on processes, data, statistical thinking, and patient satisfaction and promotes empowerment and collaboration. Quality assurance focuses on organization structure and individuals and is externally driven.
A man has just arrived in the ER with a possible myocardial infarction (MI). The electrocardiogram (ECG) should be obtained within which time frame of arrival to the ER? 10 minutes 5 minutes 15 minutes 20 minutes
10 minutes Explanation: The ECG provides information that assists in diagnosing acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the emergency department. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored.
A client is admitted with end stage pancreatic cancer and is experiencing extreme pain. The client asks the nurse if an acupuncturist can come to the hospital to help manage the pain. The nurse states, ?You won't need acupuncture. We have pain medications.? Which characteristic has the nurse displayed? Stereotyping Cultural conflict Cultural imposition Culture shock
Cultural imposition Explanation: The nurse has demonstrated cultural imposition by assuming that traditional pain relief measures are superior and the patient should conform to the nurse?s belief regarding pain control. This is not an example of cultural conflict because the nurse did not ridicule the request; it was simply dismissed.
When discussing culture, the nurse educator correctly identifies which terminology to describe a health care practitioner who is respectful of the health care traditions of other cultures? Culturally sensitive Culturally appropriate Culturally competent Culturally impositive
Culturally sensitive Explanation: Culturally sensitive is defined as being respectful of other diverse cultures, while culturally impositive is the tendency for health care practitioners to impose their beliefs, practices, and values on people of other cultures. Culturally appropriate and competent refer to the holistic care given by health care practitioners.
The nurse meets with the family of a 3-year-old child who is seriously ill. In the role as collaborator, the nurse: provides the parents with information about financial assistance programs. informs the family of the diagnosis and recently discovered findings. coordinates the multidisciplinary services and provides information about them. refers and consults with other specialties to help in treating the child's diagnosis.
coordinates the multidisciplinary services and provides information about them. Explanation: Coordinating the multidisciplinary services and providing information about them demonstrate collaboration because the nurse will be explaining the functions of social service, case management, and so forth. Providing parents with information about financial assistance programs is the responsibility of social services, not a nursing role. Informing the family of the diagnosis and recently discovered findings is a physician's responsibility as is referring and consulting with other specialties.
The client with a lumbar laminectomy asks to be turned onto the side. The nurse should: ask the client to help by using an overhead trapeze to turn. turn the client's shoulders first, followed by the hips and legs. inform the client that because of the laminectomy, it is possible to only lie supine. get another nurse to help logroll the client into position.
get another nurse to help logroll the client into position. Explanation: 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 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.
Which are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply. room number bed number medical record number name band social security (social insurance) number
medical record number name band Explanation: A National Patient Safety Goal of The Joint Commission is to improve the accuracy of client identification; to attain that goal, health care personnel must use at least two client identifiers when providing care, treatment, or services. The medical record number and name as printed on the client's name band are appropriate identifiers. Because the client can change rooms and beds, these are not to be used as identifiers. Social security number is not used as an identifier for health care or treatment purposes.
Which of the following set of terms best describes nursing at the end of the Middle Ages? continuity, caring, critical thinking purpose, direction, leadership assessment, interventions, outcomes advocacy, research, education
purpose, direction, leadership Explanation: During the Middle Ages, nursing began to have a more clearly defined role. Members of religious orders gave nursing care, nursing orders were founded, and nursing became a respected vocation. Although the Middle Ages ended in chaos, nursing had developed purpose, direction, and leadership.
A nurse working in a physician's office uses the managerial function known as "organizing." What is involved in this function? resources problems workforce evaluation
resources Explanation: The organizing function of the nurse manager involves acquiring, managing, and mobilizing resources to meet both clinical and financial objectives. Reference:
A nursing instructor is discussing burnout with a group of graduating nursing students. Which statement might lead the instructor to believe that the particular student is prone to poor coping skills? ?I'm scared they will put me on the night shift. I don?t think I have the ?chops? for that much responsibility yet.? ?I can handle almost anything now. You teachers have trained us well.? ?I hope I get a good preceptor. I know that will help me get used to this transition.? ?There?s so much to learn. I have to find a way to balance these new challenges with settling back into my regular life.?
?I can handle almost anything now. You teachers have trained us well.? Explanation: Anxiety over the uncertainty of succeeding in a new life role is to be expected. Recognizing that this will be a stressor is an important step in positive coping and adaptation. Erroneously thinking that this will not be a challenge is a form of denial, may lead to role conflict and disillusionment, and later can become a burnout situation.
A nurse is communicating the plan of care for a patient who is unconscious. Which nursing actions best facilitate this process? (Select all that apply.) The nurse speaks to the patient in a louder than normal voice. The nurse is careful what is said in the patient's presence since hearing is the last sense to go. The nurse assumes the patient can hear and discusses things that would ordinarily be discussed. The nurse raises environmental noises to help stimulate the patient. The nurse does not use touch to communicate with the patient. The nurse speaks with the patient before touching him or her.
The nurse is careful what is said in the patient's presence since hearing is the last sense to go. The nurse assumes the patient can hear and discusses things that would ordinarily be discussed. The nurse speaks with the patient before touching him or her. Explanation: The nursing actions that best facilitate communication with a client who is unconscious would include being careful what is said in the client's presence because hearing in believed to be the last sense to go. The nurse would assume the client can hear and discuss things that would ordinarily be discusses. The nurse would speak with the client before touching them. The nurse would not speak to the client in a louder than normal voice. The nurse would minimize environmental noises to facilitate communication. The nurse would use touch to communicate with the client.
The nurse is caring for an adult paraplegic with an ostomy. Which of the following would be an appropriate statement for the nurse to make? "What type of pouching system do you use, honey?" "Who changes your pouching system at home?" "Do you need assistance managing your ostomy?" "I insist that I empty your ostomy pouch now."
"Do you need assistance managing your ostomy?" Explanation: The nurse should ask the patient if he/she needs assistance managing the ostomy. The nurse should not assume that the patient is unable to care for it independently and should not refer to the patient as "honey. When caring for an adult patient with a disability, the nurse should treat the patient as an adult and offer assistance, but not insist.
A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk? 18 23 28 31
23 Explanation: Patients with a BMI of 23 would have the lowest risk for health problems. Those with a BMI of 18 might have the increased risk associated with poor nutritional status. Those with a BMI of 28 are considered overweight, and those with a BMI of 30 to 39 are considered obese. Both of these groups have an increased risk for health problems.
While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that she forgot to administer insulin to client with diabetes mellitus. She's made numerous errors in the past few weeks and is now afraid her job is in jeopardy. What is her best course of action? Administer the medication immediately and chart it as given on time. Report the error and request a private meeting with the unit manager. Report the error, complete the proper paperwork, and meet with the unit manager. Contact the physician and follow his instructions.
Report the error, complete the proper paperwork, and meet with the unit manager. Explanation: Making an error can be very stressful and a nurse may feel great pressure to hide her mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, she must still report the error and complete the proper paperwork. The nurse should contact the physician and follow his instructions, but she shouldn't bypass proper protocol.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Report the infection to an immediate supervisor. Ensure the infection is covered with a dressing. Return to work after being on antibiotics for 24 hours. Request role change to circulating nurse.
Report the infection to an immediate supervisor. Explanation: The infection needs to be reported immediately because of the asepsis environment of the operating room. The usual barriers may not protect the patient when an infection is present. The employee will need to follow the policy of the operating room regarding infections. Covering the infections with a dressing may be necessary but the infection must first be reported. The scrub nurse may still be able to work depending on the policy; therefore, returning to work after 24 hours is not the priority action. Even if the nurse requests a role change to circulating nurse, the policy for infections in the operating room must be followed; therefore, it must first be reported.
Which of the following are examples of virtues that can exemplify character and conduct as a professional nurse? Select all that apply. Trustworthiness Humility Deception Conflict Compassion
Trustworthiness Humility Compassion Explanation: Trustworthiness, humility, and compassion are all examples of professional virtues and cultivated dispositions of character and conduct that motivate and enable us to be good human beings. Deception and conflict are not positive examples so are not correct choices.
