Study Questions

A nurse is providing teaching with a nursing colleague about sentinel events. Which of the following statements by the nursing colleague indicates an understanding? "An example of a sentinel event is administering incompatible blood products to a client." "An example of a sentinel event is administering client medications 30 minutes late." "An example of a sentinel event is administering a prescribed sedative to a client for insomnia." "An example of a sentinel event is documenting vital signs at the wrong time in the client's electronic health record."

"An example of a sentinel event is administering incompatible blood products to a client." A sentinel event is an event that causes harm or results in death of a client. Administering incompatible blood products can result in harm to a client. Therefore, this is considered a sentinel event.

Beneficenceu

Doing good or causing good to be done; kindly action

Nonmaleficence

Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.

veracity

truthfulness, honesty

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention? A client who is asymptomatic is not scheduled for a series of tests. A client who has a family history of breast cancer is scheduled for a mammogram. A client is scheduled to receive an influenza vaccination A client who has heart failure is scheduled for an echocardiogram.

A client who has a family history of breast cancer is scheduled for a mammogram. A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.

A nurse is preparing an in-service about motivational interviewing for a group of staff nurses. Which of the following statements should the nurse make when discussing the OARS mnemonic? A = Providing affirmations to encourage the client O = Offering one's personal opinions to the client S = Offering sympathy based on emotionally identifying with the client R = Providing reassurance to the client that everything will be okay

A = Providing affirmations to encourage the client The letter A in OARS stands for affirmations or providing positive feedback to the client. This positive feedback can motivate a client to continue to engage in desired behavior and to achieve optimal health outcomes.

A charge nurse is providing an in-service to a group of staff nurses about unexpected events. Which of the following should the nurse include in the teaching as an example of a sentinel event? A client fell out of bed and fractured their hip. A client had bowel surgery and died from sepsis. A client was prescribed a medication they were allergic to, but the prescription was canceled before the medication was given. A client was almost given another client's medication.

A client had bowel surgery and died from sepsis.

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention? A client who has a family history of breast cancer is scheduled for a mammogram. A client who has heart failure is scheduled for an echocardiogram. A client is scheduled to receive an influenza vaccination A client who is asymptomatic is not scheduled for a series of tests.

A client who has a family history of breast cancer is scheduled for a mammogram.

A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first? A client who has early dementia and awoke confused to their location this morning. A client who is postoperative and has a urine output of 50 mL for the past 3 hr A client who has pneumonia and has developed wheezing. A client who is scheduled for discharge and has a 38.4° C (101.1° F) temperature this morning.

A client who has pneumonia and has developed wheezing. Using the ABCDE priority framework, the nurse should first see the client who has pneumonia and has developed wheezing as this can lead to a compromised airway that requires immediate attention. The nurse should check the client to determine if they can talk or if secretions are obstructing the airway, in which case suctioning of the client's airway is required.

A nurse is performing triage on several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients? A client who has a sprained left ankle A client who has an open traumatic brain injury and agonal breaths A client who has sustained a partial amputation of the right leg A client who is deceased A client who has sustained a major burn to their upper torso and extremities A client who has a fractured left fibula and tibia

A client who has sustained a partial amputation of the right leg A client who has sustained a major burn to their upper torso and extremities

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A client with a minor laceration on the index finger sustained while cutting an eggplant A client with chest pain who states that he just ate pizza that was made with a very spicy sauce A client who twisted her ankle when rollerblading and is requesting medication for pain A client complaining of muscle aches, a headache, and history of seizures

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

The nurse who fails to remove a patient from an unsafe situation has violated which bioethical principle? Beneficence Justice Veracity Fidelity

Beneficence The nurse who fails to remove a patient from an unsafe situation violates the bioethical principle of beneficence, which means to prevent harm, or promote good.

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders strictly enforce rules to maintain compliance? Transformational leader Situational leader Bureaucratic leader Laissez-faire leader

Bureaucratic leader Bureaucratic leaders are rule-based. They are not open to creativity and strictly enforce the rules to maintain compliance.

The nurse who respects the patient's right to refuse treatment is following which bioethical principle? Beneficence Justice Fidelity Autonomy

Autonomy Autonomy refers to the patient's right to refuse treatment and to make one's own decisions regarding health care. Justice, beneficence, and fidelity refer to fairness, doing no harm, and truth-telling.

A nurse is teaching a class on leadership. The nurse should include that which of the following is a characteristic of situational leaders? A)Strictly enforces rules to maintain compliance B)Uses rewards or punishments to encourage compliance C)Adjusts quickly to different circumstances D)Focuses on long-term goals

C)Adjusts quickly to different circumstances A situational leader looks at each situation quickly and adjusts strategies based on the circumstances. They communicate, problem-solve, organize, and prepare with their employees to accomplish tasks and improve overall efficiency.

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction? Distended jugular veins. Blood pressure 184/92 mm Hg. Bilateral flank pain. Generalized urticaria.

Generalized urticaria. a rash of round, red welts on the skin that itch intensely, The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm.

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication? Veracity Fidelity Utilitarianism Nonmaleficence

Nonmaleficence Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.

A nurse is teaching a class about the roles and responsibilities of a case manager. Which of the following responsibilities should the nurse include? Teaches nursing students Provides direct client care Collects and utilizes data to change current practice Organizes client services following discharge

Organizes client services following discharge The case manager communicates with the interprofessional team to coordinate client services while the client is in the health care facility and when the client is discharged.

A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Using the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the clients' situation? Esteem Self-actualization Physiological Safety

Physiological The nurse should identify that clients who have lost their home are experiencing physiological needs according to Maslow's hierarchy. Shelter is a basic physiological need for survival.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction? Pallor Report of metallic taste Report of low-back pain Hypertension

Report of low-back pain Low-back pain, fever, and chills are manifestations of a hemolytic transfusion reaction. The nurse should discontinue the transfusion and administer 0.9% sodium chloride through new IV tubing

A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing? Researcher Case manager Educator Nurse manager

Researcher The nurse is performing the role of a researcher. A nurse researcher gathers evidence-based practice data on a topic such as CAUTI which is supported with scientific research to show its effectiveness. This can assist with the improvement of quality care given to clients.

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy? Making sure the client understands expectations for client participation Supporting the client's wish to refuse prescribed medications Encouraging client feedback about satisfaction with the facility experience Explaining unit rules and policies regarding unacceptable behaviors

Supporting the client's wish to refuse prescribed medications

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy? Making sure the client understands expectations for client participation Supporting the client's wish to refuse prescribed medications Encouraging client feedback about satisfaction with the facility experience Explaining unit rules and policies regarding unacceptable behaviors

Supporting the client's wish to refuse prescribed medications Supporting the client's wishes is an important component of client advocacy.

A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse? The nurse starts the transfusion of another unit of blood product. The nurse collects a urine specimen. The nurse sends a blood specimen to the laboratory. The nurse initiates an infusion of 0.9% sodium chloride.

The nurse starts the transfusion of another unit of blood product. When suspecting a hemolytic reaction, the nurse should immediately stop the transfusion of all blood products. The transfusion of additional products can increase the client's risk for further complication.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? The patient is short of breath on exertion. The patient complains of chest pain. The patient states, "I feel nauseous." The patient complains of feeling faint.

The patient is short of breath on exertion.

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders identifies common values to empower employees? Bureaucratic leader Transactional leader Transformational leader Laissez-faire leader

Transformational leader

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders identifies common values to empower employees? Transactional leader Laissez-faire leader Transformational leader Bureaucratic leader

Transformational leader Transformational leaders establish a common mission and vision. They encourage empowerment in employees to elevate their level of performance.

Fidelity and Responsibility

establish relationships of trust; accept responsibility for professional behavior

Utilitarianism

idea that the goal of society should be to bring about the greatest happiness for the greatest number of people

Which action by the nurse indicates placement in the unfreezing phase of Lewin's Change Theory? The nurse reconsiders if he or she is resistant to change. The nurse begins the process of implementing change. The change has become routine. The change is permanent.

the nurse reconsiders if he or she is resistant to change. Lewin's Change Theory consists of three phases: unfreezing, moving, and refreezing. In the unfreezing phase, the nurse reconsiders what has caused him or her to be resistant to change.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? The patient complains of feeling faint. The patient is short of breath on exertion. The patient complains of chest pain. The patient states, "I feel nauseous."

the patient is short of breath on exertion.