The Nursing Process
A nurse asks a nursing colleague to witness a narcotic waste. The nurse says, "On night shift we just sign for it and no one really watches the waste." What is the best response by the nurse witnessing the narcotic waste? Select all that apply. - "I cannot just sign and not witness the waste." - "I think your team works well together on this unit." - "I will need to witness the waste before I sign for it." - "I will do it the same way you are used to doing the waste." - "I would be careful if you are not following the hospital policy."
- "I cannot just sign and not witness the waste." - "I will need to witness the waste before I sign for it." Explanation: The nurse is following standard practice by witnessing and signing for the narcotic waste. If the nurse agrees to sign and not witness, then the standard is not being followed. Making a statement in reference to teamwork or following policy will not support the correct method for wasting a narcotic.
An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. - Apply lanolin or petroleum jelly to intact skin. - Encourage a reduced-calorie, reduced-fat diet. - Inspect the involved areas daily for new ulcerations. - Limit activities of daily living (ADLs). - Use an electric razor to shave.
- Apply lanolin or petroleum jelly to intact skin. - Encourage a reduced-calorie, reduced-fat diet. - Inspect the involved areas daily for new ulcerations. - Use an electric razor to shave. Explanation: Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving warfarin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body.
The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply. - Determine that there will be a latex-safe environment for surgery. - Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). - Notify the health care providers (HCPs) at the surgery center. - Wear a stainless steel medical alert bracelet into the surgical suite. - Ask to have the surgery at a hospital.
- Determine that there will be a latex-safe environment for surgery. - Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). - Notify the health care providers (HCPs) at the surgery center. Explanation: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs and symptoms of latex allergy may range from mild to anaphylaxis. Clients with latex allergy are advised to notify their HCPs and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current. The surgery can be safely performed at a free-standing surgery center as long as latex precautions are observed.
Which situation is an indication of the benefit of self-awareness in professional nursing practice by a nurse? Select all that apply. - Examines own biases and is open to new ideas - No longer is affected by biases and assumptions - Appears more tolerant to different practices - Questions all situations for underlying meanings - Understands the meaning of cultural diversity
- Examines own biases and is open to new ideas - Understands the meaning of cultural diversity Explanation: Self-awareness in nurses allows openness and a willingness to examine one's beliefs and consider new ideas. Understanding the meaning of cultural diversity also shows self-awareness. Appearing more tolerant to different practices means willingness to accept others' beliefs, but doesn't necessarily mean examining one's own beliefs. To question all situations for underlying meaning is not an example of self-awareness and self-reflection.
The nursing instructor is discussing protecting clients' rights with nursing students. The students should identify that which events are technology privacy safeguards used in nursing? Select all that apply. - The nurse refrains from taking clients' photographs. - The nurse obtains consent for hospital admission announcement. - The nurse secures health care records for employee access only. - The nurse accesses assigned client medical records. - The nurse prints client medication records for students to research medications.
- The nurse refrains from taking clients' photographs. - The nurse obtains consent for hospital admission announcement. - The nurse secures health care records for employee access only. - The nurse accesses assigned client medical records. Explanation: The nurse protects clients' privacy by avoiding taking clients' photographs, obtaining consent for hospital admission announcement, protecting health care records, and accessing assigned client medical records. Printing client medication records for students' research is a not safeguarding clients' rights.
Which actions by the nurse are appropriate when planning care for a client admitted to the intensive care unit after a spinal cord injury? Select all that apply. - identifying the cause of the injury - having the client set the care schedule - gauging level of progress weekly - prioritizing areas of client need - retiring problems that are resolved
- identifying the cause of the injury - having the client set the care schedule - gauging level of progress weekly Explanation: During the nursing process, the nurse collects data about the client and family, forms and prioritizes nursing problems, plans and implements methods to meet client care needs, and evaluates the effectiveness of the interventions. The nurse should collaborate with the client and the family while developing and implementing the plan of care. However, allowing the client to set the care schedule without nursing input may not completely meet client needs. Identifying the cause of the injury is not part of the nursing process.
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. - to ensure efficient and accurate communication - to prevent medication errors - to ensure client safety - to make it easier for clients to understand the medication prescription - to make data entry into a computerized health record easier
- to ensure efficient and accurate communication - to prevent medication errors - to ensure client safety Explanation: Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication prescriptions or to make data entry easier.
A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation? a. "Your verbal threats to the client are legally considered assault." b. "I think you need to review therapeutic communication techniques." c. "Could you clarify for me whether you were joking with the client?" d. "I will have to report you for unprofessional behavior toward a client."
a. "Your verbal threats to the client are legally considered assault." Explanation: Assault is conduct that makes a person fearful and produces a reasonable apprehension of harm. The nurse's behavior in legal terms is assault.
After many years of advanced practice nursing, a nurse has recently enrolled in a nurse practitioner (NP) program. This nurse has been attracted to the program by the potential after graduation to provide primary care for clients, an opportunity that is most likely to exist in which setting? a. A rural health center. b. A long-term care facility. c. A university hospital. d. A community hospital.
a. A rural health center. Explanation: Many rural health centers employ few healthcare providers, and primary care is often provided by an NP. An NP may provide care in a long-term care facility or hospital, but in these settings, the NP is less likely to be the provider of primary care to clients.
A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg, and the pulse is 98 bpm. What should the nurse do? a. Administer lorazepam. b. Administer an antihypertensive. c. Assign an unlicensed assistive personnel to sit with the client. d. Notify the health care provider.
a. Administer lorazepam. Explanation: Lorazepam, a benzodiazepine, is commonly used to decrease the symptoms of central nervous system irritability in the client who is experiencing early symptoms of alcohol withdrawal. An antihypertensive will not treat the underlying CNS irritability. If the lorazepam is effective, it will not be necessary to have someone sit with the client. At this point, it is not necessary to notify the health care provider (HCP).
The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next? a. Give the incident report to the nurse-manager. b. Place the incident report on the medical record. c. Call the family to inform them. d. Omit mentioning the fall in the medical record documentation.
a. Give the incident report to the nurse-manager. Explanation: The incident report should be given to the nurse-manager. The incident report should not be placed on the medical record because it is considered a confidential communication and cannot be subpoenaed by a client or used as evidence in lawsuits. It is appropriate, ethical, and legally required that the fall be documented in the medical record. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse-manager or the HCP should place the call.
A client has signed a document indicating a wish not to be resuscitated. During morning rounds, the nurse finds the client without vital signs. What is the most appropriate action for the nurse to take? a. Notify the physician that the client has no vital signs. b. Begin CPR until the family can be notified. c. Call the supervisor for further directions. d. Review the client's chart to verify resuscitation status.
a. Notify the physician that the client has no vital signs. Explanation: The client has signed a document indicating a wish not to be resuscitated. The other options are incorrect because the nurse should be aware of the client's "do not resuscitate" (DNR) status and should not need to go to the desk to confirm this. The nurse should notify the physician so the physician can pronounce the death and notify the family.
A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be? a. The nurse should ask the person to talk to the family directly. b. The nurse should invite the person to learn the caring techniques. c. The nurse should state that the family does not need any help. d. The nurse should refer the person to the local social worker.
a. The nurse should ask the person to talk to the family directly. Explanation: The nurse should ask the person to talk to the family directly. Revealing information about the client's care is a violation of the client's privacy. The nurse should not invite the person for a learning session because doing so would be a breach of the client's right to privacy. Referring the person to a social worker is not an appropriate choice.
A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which documentation method should the nurse suggest? a. charting by exception b. medication administration records c. problem, intervention, and evaluation note d. focus data, action, and response note
a. charting by exception Explanation: The nurse should suggest the use of charting by exception, which is an abbreviated form of documentation. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a focus can be a problem area, but does not need to be. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The medication administration record documents only medication administration.
A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a. identifying risks and ensuring future safety for clients b. gauging the nurse's professional performance over time c. protecting the nurse and the hospital from litigation d. following up on the incident with other members of the care team
a. identifying risks and ensuring future safety for clients Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action and they are not commonly used to communicate within the interdisciplinary team.
A nurse discusses the HIV-positive status of a client with other colleagues. The client can sue the nurse for which violation? a. invasion of privacy b. defamation of character c. professional negligence d. false imprisonment
a. invasion of privacy Explanation: The client can sue the nurse for invasion of privacy. Disclosing confidential information to an inappropriate third party subjects the nurse to liability for invasion of privacy, even if the information is true. Defamation of character includes false communication that results in injury to a person's reputation. Prevention of movement or unjustified retention of a person without consent may be false imprisonment. Negligence is an act of omission or commission.
While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: a. report this to the nursing supervisor immediately. b. report this to the head nurse in the morning. c. ask the nurse if she has been drinking. d. assess the nurse's behavior for signs of intoxication.
a. report this to the nursing supervisor immediately. Explanation: This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed until the head nurse is available on the day shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.
A client asks to read the medical record. What should the nurse do? a. Call the health care provider (HCP) to obtain permission. b. Give the client the medical record and answer the client's questions. c. Tell the client to read the medical record when the health care provider (HCP) makes rounds. d. Answer any questions the client has without giving the client the medical record.
b. Give the client the medical record and answer the client's questions. Explanation: The client should be allowed to see the medical record. As a client advocate, the nurse should answer questions for the client. The nurse helps the client become a primary partner in the health team. The HCP should not need to give permission for the client to see the medical record. As a client advocate, the nurse should not make excuses to put the client off in regard to seeing the medical record.
When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next? a. Have the client's next-of-kin sign the informed consent. b. Have the client put an "X" on the signature line. c. Have a court appoint a guardian for the client. d. Have a hospital quality management coordinator sign for the client.
b. Have the client put an "X" on the signature line. Explanation: The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary.
A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation? a. Perform morning care while the client is handcuffed. b. Insist that the officers stay in the room at all times. c. Ask another nurse to come into the room. d. Ask one of the officers to remove the handcuffs.
b. Insist that the officers stay in the room at all times. Explanation: A correctional officer should be with the client at all times. To protect the safety of the nurse and the client, the nurse should refuse to administer care without an officer present. The other options put the nurse and the client at risk.
A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first? a. Monitor the coworker's behaviors. b. Report the suspicion to the nurse manager. c. Discuss the suspicion directly with the coworker. d. Keep track of the quantity of medications in the cart throughout the shift.
b. Report the suspicion to the nurse manager. Explanation: The nurse should report the suspicion to the nurse manager. The American Nurses Association does not advise confronting coworkers in these situations. Monitoring the coworker's behavior or keeping track of the quantity of medications in the cart do not solve these problem. These actions allow the coworker to continue working with clients while possibly under the influence of drugs, which is not safe.
A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the bestway for the nurse to determine how to catch up the child's vaccinations? a. Contact the child's health care provider (HCP) during office hours. b. Review nationally published immunization guidelines. c. Read each vaccine's manufacturer's insert. d. Ask a local pharmacist on duty.
b. Review nationally published immunization guidelines. Explanation: National advisory committees on immunization practices review vaccination evidence and update recommendations yearly. Current vaccination catch-up schedules are readily available on their websites. The lack of vaccinations is a strong indicator that the child probably does not have an HCP. Even if the client had a provider, however, that person might be difficult to reach on a weekend during the time frame of a vaccination clinic. If consulted, the pharmacist would most likely have to review the latest guidelines that are equally available to the nurse. Reading each of the manufacturer's inserts for multiple vaccines would be time consuming, and synthesis of the information could possibly lead to errors.
A "read-back" procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. When should this procedure be implemented? a. When the float nurse gives a written report to the oncoming nurse b. When the nurse receives a critical lab value via phone or in-person from the lab c. When the lab report shows up on the computerized medical record d. When the unit clerk takes a telephone prescription for a stat lab test
b. When the nurse receives a critical lab value via phone or in-person from the lab Explanation: For any verbal or telephone prescription or result, it is important to read back the information to assure its accuracy. It is also important to document that it was read back according to facility policy. It is not necessary to use "read-back" procedures when data are entered on the computerized medical record. The Unit clerk is not a licensed health care worker and should not take telephone prescriptions. When giving a written report, it is not necessary to "read back," but the nurse should always clarify if there is any question.
There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital? a. a 10-year-old with a simple fracture of the femur, who is crying and cannot find his parents b. a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious c. middle-aged male with severe asthma, heart rate of 120 bpm, and is having difficulty breathing d. an older adult with severe headache, but conscious
b. a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious Explanation: The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 min. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 min.
A client with major depression and psychotic features is admitted involuntarily to the hospital. He will not eat because his "bowels have turned to jelly," which the client states is punishment for his wickedness. The client requests to leave the hospital. The nurse denies the request because commitment papers have been initiated by the health care provider. The nurse understands this client legally committable based on which criterion? a. evidence of psychosis b. being gravely disabled c. risk of harm to self or others d. diagnosis of mental illness
b. being gravely disabled Explanation: Criteria for commitment include being gravely disabled and posing a harm to self or others. This client is not threatening to harm himself in the form of suicide or to harm others. The client is gravely disabled because of his inability to care for himself—namely, not eating because of his delusion. Evidence of psychosis or psychotic symptoms or diagnosis of a mental illness alone does not make the client legally eligible for commitment.
A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? a. "Do you have a history of GERD (gastroesophageal reflux disease)?" b. "Have you ever had pain like this before?" c. "What were you doing when the pain started?" d. "Do you take any medications on a regular basis?"
c. "What were you doing when the pain started?" Explanation: Subjective data (data from the client) about the chest pain helps the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking about the history and medications will yield helpful information, but would not be the most helpful.
A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take? a. Strike through the entry ensuring the original entry is still visible. b. Rewrite the entry on the correct health record indicating who made the error. c. Contact the previous nurse requesting that the nurse correct the error. d. Report to the nurse manager that the nurse needs guidance on documentation.
c. Contact the previous nurse requesting that the nurse correct the error. Explanation: The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.
A hospitalized client fell on the floor and sustained a small laceration on the hand that requires stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. Which issue should be resolved before proceeding with suturing? a. the intern's ability to suture. b. the client's room as an aseptic environment. c. bupivacaine with epinephrine used as the local anesthetic. d. the cosmetic effect from not having a plastic surgeon do the suturing.
c. bupivacaine with epinephrine used as the local anesthetic. Explanation: The nurse should question the use of a local anesthetic agent with epinephrine on the hands or feet because the epinephrine is a vasoconstrictor and can cause ischemia and gangrene of extremities. The nurse should suggest that the intern use bupivacaine without epinephrine as the local anesthetic agent. An intern should be trained in suturing small superficial incisions, and the cosmetic effect should be acceptable. The client's room should be a sufficiently aseptic environment because there is no other client in the room.
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The health care provider (HCP) has prescribed 1,000 mL 5% dextrose in water to be infused every 8 hours. What should the nurse do before implementing the HCP's prescriptions? Contact the health care provider (HCP) and: a. suggest adding potassium to the fluids. b. request an increase in the volume of intravenous fluids. c. verify the prescription for 5% dextrose in water. d. determine if the client should be placed in isolation.
c. verify the prescription for 5% dextrose in water. Explanation: The client needs fluid volume replacement due to the dehydration. However, the nurse should verify the prescription for IV dextrose with the HCP due to the risk of hyperglycemia that dextrose would present when administered to a client with diabetes. The potassium level is within normal limits. The client does not have restrictions on oral fluids, and the nurse can encourage the client to drink fluids. The client does not need to be placed in isolation at this time.
A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? a. Instruct the client not to move while the restraints are in place. b. Remove the restraints every 4 hours to provide skin care. c. Secure the restraints to side rails of the bed. d. Check on the client every 30 minutes while the restraints are on.
d. Check on the client every 30 minutes while the restraints are on. Explanation: The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.
A mentally incapacitated client is scheduled for surgery. Considering the principle of autonomy, who should give the consent for surgery? a. client b. operating surgeon c. attending nurse d. surrogate decision maker
d. surrogate decision maker Explanation: A surrogate decision maker should be identified to give consent for the mentally incapacitated client. Infants, young children, people who are severely mentally handicapped or incapacitated, and people in a persistent vegetative state or coma do not have the capacity to participate in decision making about their healthcare. For such people, a surrogate decision maker must be identified to act on their behalf. The surgeon and the nurse are not eligible to give consent for the client.