Saunders Unit II Issues in Nursing Q 13-25

22. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistance personnel (UAP) tells the group that she thinks that the unit secretary has AIDS and proceeds to tell the nursing staff that the secratary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? 1. Libel 2. Slander 3. Assault 4. Negligence

2. Slander Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

17. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security 2. Call the police 3. Call the nursing supervisor 4. Lock the coworker in the medication room until help is obtained.

3. Call the nursing supervisor Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.

13. A nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed 2. The client climbed over the side rails 3. The client was found lying on the floor 4. The client became restless and tried to get out of bed

3. The client was found lying on the floor The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved,and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Option 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

19. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? 1. Documenting a late entry into the client's record 2. Trying to erase the error for space to write in the correct data 3. Using whiteout to delete the error to write in the correct data 4. Drawing one line through the error, initialing and dating, and then documenting the correct information

4. Drawing one line through the error, initialing and dating, and then documenting the correct information If the nurse makes an error in narrative documentaiton in the client's record. The nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing, and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record and the use of whiteout are prohibited.

24. The nurse calls the health care provider regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor 2. Administer the dose prescribed 3. Hold the medication until the HCP can be contacted 4. Administer the recommended dose until the HCP can be located

1. Contact the nursing supervisor If the HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

15. The nurse has assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client 2. Conduct a staff meeting to describe the fall 3. Document the nurse's notes that an incident report was completed 4. Contact the nursing supervisor to update information regarding informed consent

1. Reassess the client After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

20. Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 3. The client seemed angry when awakened for vital sign measurement 4. The client appears to become anxious when it is time for respiratory treatments 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema

1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms such as seemed or appears is not acceptable because the words suggest that the nurse is stating an opinion.

25. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate nursing action. 1. Call the police 2. Cut up the photograph and throw it away 3. Call the nursing supervisor and report the incident 4. Call the laboratory and ask for the individual's name who sent the photograph

3. Call the nursing supervisor and report the incident Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcomed sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Option 2 and 4 are in appropriate initial actions.

14. A client is brought to the emergency room department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious . An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure 2. Ask the EMS team to sign the informed consent 3. Transport the victim to the operating room for surgery 4. Call the police to identify the client and locate family

3. Transport the victim to the operating room for surgery In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action.

23. An 87 year old woman is brought to the emergency room department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1. "Oh, really. I will discuss this situation with your son." 2. Let's talk about the ways you can manage your time to prevent this from happening." 3. "Do you have any friends that can help you out until you resolve these important issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." The nurse must report situations related to child or elder abuse, gunshot wounds, and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

18. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. the Client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request."

4. "I will call the nursing supervisor to seek assistance regarding your request." Living wills, also known as natural death acts in some states, are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding living wills vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care from being a witness. Option 2 is non therapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

16. The nurse arrives at work and is told to report (float) to the ICU for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? 1. Call the hospital lawyer 2. Refuse to float to the ICU 3. Call the nursing supervisor 4. Identify tasks that can be performed safely in the ICU

4. Identify tasks that can be performed safely in the ICU Floating is an acceptable legal practice used by hospitals to solve under staffing problems. Legally, the nurse cannot refuse to float unless a union contact guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.

21. A nursing instructor delivers a lecture to nursing students regarding the issue of the client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.