Leadership Exam 3

The nurse-manager notes an unacceptable rate of falls on the unit. Hourly rounds by nursing staff are initiated. What is the best method to determine that the change has made a difference? 1. Scores on client satisfaction surveys 2. surveys on staff's perception of the effectiveness 3. comparing fall rates after the rounds are initiated 4. documentation that the rounds are completed as scheduled

3. comparing fall rates after the rounds are initiated

If a nurse applies a restraint vest without the patient's permission or a physician's order, the nurse may be charged with (select all that apply) A. Invasion of privacy B. Battery C. Assault D. Neglect E. False Imprisonment

B and E

The Quality Improvement Team is considering an initiative to prevent falls. Which action will be most successful? A. Frequent rounds of patient rooms. B. Placing all beds in the low position. C. Using color-coded wristbands. D. Putting a "Fall Risk" sign on patient doors

A. Frequent rounds of patient rooms. When staff makes rounds, they are able to notice current risks and can intervene right away. Rounds also provide the opportunity for teaching patients and families about fall risks.

Which ethical principle is used when a client asks about her prognosis? A. Nonmaleficence B. Veracity C. Beneficence D. Fidelity

B. Veracity Veracity is the ethical principle that means to tell the truth. There can be no mistruth or deceit. Beneficence is the duty to do good and promote kindness. Fidelity is being faithful and keeping promises. Nonmaleficence is the duty not to harm, as well as prevent harm.

A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle 1. Beneficence 2.Veracity 3. Autonomy 4. Privacy

3. Autonomy Autonomy is the right of individuals to take action for themselves. Beneficence is duty to help others by doing what is best for them, whereas negligence is a legal term. Veracity is truthfulness. Privacy is the nondisclosure of information by the health care team.

A staff nurse at the nurse's station answers the phone and is told there is a bomb in a client's room. What action should the nurse take? 1. put call on hold and obtain charge nurse 2. transfer call to security 3. ask caller for details about the bomb placement 4. signal to staff to close the clients door

3. ask caller for details about the bomb placement with potential danger, it is important to determine as much information as possible

A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle? 1. beneficence 2. veracity 3. autonomy 4. privacy

3. autonomy Autonomy is the right of individuals to take action for themselves. Beneficence is an ethical principle to do good and applies when the nurse has a duty to help others by doing what is best for them. Veracity refers to truthfullness. Privacy is the nondisclosure of information by the health care team.

A client asks why a diagnostic test has been ordered and the nurse replies, "I'm unsure but will find out for you." When the nurse later returns and provides an explanation, the nurse is acting under which principle? 1. Nonmaleficence 2. Veracity 3. Beneficence 4. Fidelity

4. Fidelity Fidelity means to be faithful to agreements and promises. This nurse is acting on the client's behalf to obtain needed information and report it back to the client. Nonmaleficence is duty to do no harm. Veracity refers to telling the truth—for example, not lying to a client about a serious prognosis. Beneficence means doing good, such as by implementing actions (keeping a salt shaker out of sight) that benefit a client (heart condition requiring sodium-restricted diet).

In the event of a fire in a client's home, your first action is to _______. A. report the fire to your agency. B. get the fire extinguisher. C. move the client to a safe place. D. turn on the fire alarm

The nurse should be familiar with exits and location of fire extinguishers. If a smoke or fire alarm sounds, your first action is to keep the client safe. Remember "R.A.C.E." to quickly act. R = Rescue/Remove the client. A = Alarm, if the alarm is not connected to the fire department, call 911 to report it. . C = Confine/Contain the fire or smoke by closing doors to prevent or slow the spread. Smoke is especially dangerous for everyone. E = Extinguish the fire if possible, using a handheld fire extinguisher. Attempt to extinguish only small fires, as long as you and the client can remain safe, and have an escape route

The director of a level one trauma center is planning one of the two yearly required hospital-wide disaster drills. The director begins instructing some of the nurse managers on the requirements of the drill. Which statements by the managers indicate that the teaching has been effective? Select all that apply. A. "One of the drills must use community-wide resources." B. "Hospitals are the only health care facilities required to practice drills." C. "A drill must be completed when a new employee is hired at the facility." D. "Once we have a plan in place, we do not need to regularly participate in drills." E. "To maintain ongoing disaster preparedness, we must participate in drills and emergency training at least twice a year."

A and E Rationale: Disaster drills are completed by health care facilities to ensure competence and to test the facility's disaster plan. The plan can then be modified as needed. Teaching has been effective when a manager states that one of the two required drills must use community-wide resources. During a disaster situation, the hospital will draw on additional resources to assist victims. The manager is also correct when stating that the hospital must participate in drills and emergency training regularly in order to be prepared. Without proper training and testing the disaster plan, the hospital is not likely to succeed in adequately treating disaster victims. Hospitals are not the only health care facilities that are required to participate in disaster drills. Nursing homes and other long-term care facilities have requirements regarding participation as well. The Joint Commission requires that health care facilities participate in drills twice yearly. It is not a requirement to practice drills when a new employee is hired, though the new employee should be made aware of the disaster plan.

An emergency department nurse is a member of an All-Hazards Disaster Preparedness planning group. The group is developing a specific emergency response plan in the event that a client with smallpox arrives in the emergency department. Which interventions should be included in the plan? Select all that apply. A. Isolate the client. B. Don protective equipment immediately. C. Notify infectious disease specialists, public health officials, and the police. D. Lock down the emergency department and the entire hospital immediately. E. Identify all client contacts, including transport services to the emergency department and clients in the waiting room. F. Administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room immediately.

A, B, C, E Rationale: An All-Hazards Disaster Preparedness group is a multifaceted internal and external disaster preparedness group that establishes action plans for every type of disaster or combination of disaster events. In the event of emergency department exposure to a communicable disease such as smallpox, the client would be isolated immediately and the staff would immediately don protective equipment. The emergency department would be locked down immediately. Locking down the entire hospital may not be necessary and infectious disease specialists and public health officials will determine whether it is necessary to take this action. Infectious disease specialists, public health officials, and the police are notified. All client contacts (name, addresses, telephone numbers), including transport services to the emergency department and clients in the waiting room, would be identified so that the public health department can follow through on notifying and treating these individuals appropriately. Although getting the vaccine within 3 days after exposure will help prevent the disease or make it less severe, it is unreasonable and unnecessary to administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room.

The nurse manager is updating the trauma center's policies regarding internal disasters, such as a fire. Which action by the nurse meets the outcome of maintaining client, staff, and visitor safety? Select all that apply. A. Removing clients from harm's way B. Evacuating visitors away from a fire C. Avoiding risk while putting out a fire D. Leaving the facility immediately and going directly home E. Discontinuing oxygen on clients who can breathe without it

A, B, C, E Rationale: An internal disaster involves any event that occurs within the health care facility that could harm clients or staff. In order to maintain client, staff, and visitor safety, nurses should immediately remove visitors and clients away from a fire. The nurse should take care in putting out a fire so as to avoid any risk to self or others. In order to protect clients from harm, the nurse should discontinue oxygen on all clients who can breathe without it. Leaving the facility and going home would not meet the outcome of maintaining client, visitor, and staff safety and could be considered client abandonment.

The nurse manager is providing an educational session to the nursing staff in a skilled nursing facility on the guidelines for the safe use of physical restraints. Which are safe guidelines? Select all that apply. A. A health care provider's prescription is required. B. Restraints should be secured with a quick-release tie. C. Restraints are secured to side rails so that they can be easily removed as necessary. D. Restraints are used when other measures have failed to prevent self-injury or injury to others. E. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms. F. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them.

A, B, D Rationale: A physical restraint is a mechanical or physical device that is used to immobilize a client or extremity. It restricts the freedom of movement or normal access to a client's body. A health care provider's prescription is required for the use of restraints. Restraints should be secured with a quick-release tie so that they can be easily removed in an emergency. Restraints are considered for use only when other measures have failed to prevent self-injury or injury to others. Restraints are secured to the bed frame, not the side rails, because the client may be injured if the side rail is lowered. Restraints are not a usual part of treatment plans, indicated by the person's condition or symptoms, and are not prescribed on a PRN basis.

The nurse manager is creating a plan of action for the emergency department in the event of an internal fire. What should the nurse include in the plan? Select all that apply. A. Direct ambulating clients to walk to a safe location. B. Continue oxygen for all clients to reduce damage to lung tissue. C. Remove all clients from danger before attempting to extinguish the fire. D. Wait for the fire department to arrive before initiating the plan of action. E. Move bedridden clients away from the fire area by use of beds or stretchers.

A, C, E Rationale: The nurse has many roles in responding to fires in the health care facility. The nurse should remove all clients and visitors away from the fire. Ambulating clients should be directed toward a safe location. Oxygen is considered flammable; therefore, all clients who can breathe without oxygen should not use it. The nurse should not wait for the fire department to arrive, but should act immediately to protect clients from harm. Clients who are bedridden should be moved away from the fire by use of beds or stretchers.

The nurse educator has just finished teaching a course on disaster preparedness to a group of nurses. Which statements by one of the nurses indicate that the teaching has been effective? Select all that apply. A. "Nurses test plans by participating in disaster drills." B. "Nurses are not a key part of disaster preparedness." C. "Nurses do not evaluate the outcomes of disaster drills." D. "Nurses play key roles before, during, and after a disaster." E. "Nurses assist in developing internal and external emergency response plans."

A, D, E Rationale: The roles and responsibilities of health care personnel in a mass casualty event or disaster are defined within the institution's emergency response or preparedness plan. Nurses test emergency plans by participating in disaster drills, playing key roles before, during, and after a disaster. After analyzing and evaluating these plans, nurses assist in developing internal and external emergency response plans that are most appropriate for their institution.

Which patient has the highest risk of falling? A. A 75-year old female with episodes of syncope. B. A 36-year old female with a fractured tibia. C. A 22-year old male with 3 fractured ribs and right arm in a cast. D. A 63-year old male with angina pectoris.

A. A 75-year old female with episodes of syncope. Because of age and unexpected syncope, the 75-year old female is at the greatest risk of falling. The nurse should observe the patient's balance and gait; the patient may require assistance when ambulating, even when going to the bathroom.

A hurricane is forecasted to make a landfall in 48 hours; the emergency department at a local hospital is advised to prepare for the event of potential casualties. If any casualties occur, they will immediately be brought to the emergency department. The nurse manager who received the telephone call regarding this warning should take which initial action? A. Activate the agency disaster plan. B. Supply the triage rooms with additional equipment. C. Increase the number of nursing staff for the day that the hurricane is expected. D. Call the hospital maintenance department to secure the building from the storm.

A. Activate the agency disaster plan. Rationale: In an external disaster, many people may be brought to the emergency department for treatment. Although options 2 and 3 may be a component of preparing for the casualties, the initial nursing action must be to activate the disaster plan. Option 4 is not a responsibility that falls within the scope of nursing management, and if securing the building from a storm is required, this would be implemented by the specific hospital department delegated to perform that task.

A small plane carrying the football team from the local university crashes and survivors are being transported to the hospital. Four team members died in the crash. Before the survivors reach the hospital, what should the nurse anticipate being asked to do? A. Call the nearest crisis response team B. Call the hospital's volunteer office C. Alert the local news station D. Notify the university of the crash

A. Call the nearest crisis response team After a traumatic event, there will be a great need for support from disaster and crisis specialists. The survivors, families of the deceased team members, fellow students, and the community will need empathy and counseling. News media usually monitor emergency radio, so they will already be aware. Volunteers may be helpful, but are not experts in assisting with disasters. The university will receive information from other sources.

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires wrist restraints. The nurse determines that the unlicensed assistive personnel (UAP) is providing safe care if the nurse observed the UAP assessing skin integrity by completely removing the client's wrist restraints using which time frame? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 6 hours

A. Every 2 hours Rationale: Restraints should be completely removed for a brief period at least every 2 hours, and this action should be documented. The color of the extremity should be noted and the pulse should be assessed. The client should be asked to move the extremity, or passive range of motion exercises should be performed if the client cannot move the extremity on their own. Agency guidelines regarding the use of restraints should always be followed.

The nursing assistant is caring for a client who had a hip pinned after being fractured. The registered nurse intervenes and determines the nursing assistant needs further teaching if the nurse observes the nursing assistant taking which action? A. Leaving both side rails down on the bed B. Answering the client's call bell promptly C. Keeping the call bell within the client's reach D. Placing the client's personal articles and telephone within reach

A. Leaving both side rails down on the bed Rationale: Safe nursing actions intended to prevent injury to the client include keeping side rails up, the bed in low position, providing a call bell that is within the client's reach, and placing the client's personal articles and telephone within reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall.

The nurse administers digoxin (Lanoxin) 0.25 mg by mouth rather than the prescribed dose of 0.125 mg to the client. Which should the nurse implement first? A. Write an incident report. B. Tell the client about the medication error. C. Administer digoxin immune Fab (Digibind). D. Tell the client about the adverse effects of digoxin.

A. Write an incident report. Rationale: According to agency policy, the nurse should file an incident report when a medication error occurs to accurately document the facts. The nurse should assess the client first and then contact the health care provider (HCP) because in this situation the client received too much medication. The client should be informed of the error and the adverse effects in a professional manner to avoid alarm and concern. However, in many situations, the HCP prefers to discuss this with the client. Digoxin immune Fab is reserved for extreme toxicity and requires a prescription and may be prescribed depending on the client's response and the serum digoxin level.

The registered nurse (RN) is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. A. "An event is termed a mass casualty when it overwhelms local medical capabilities." B. "Mass casualty events do not require an increase in the number of staff needed." C. "A mass casualty event occurs only within the heath care facility and could endanger staff." D. "Mass casualty events may require the collaboration of many local agencies to handle the situation." E. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

B, C, E Rationale: Mass casualty events, also known as disasters, overwhelm local medical capabilities. This type of event can occur within the health care facility or outside of it. Mass casualty events almost always require an increase in staffing to ensure safe client care. Fights within the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events may require the collaboration of multiple agencies and health care facilities to handle the crisis.

The nurse administers furosemide (Lasix) 80 mg by mouth, but the prescription is written for furosemide 40 mg by mouth. Which should the nurse document on an incident report? A. "I gave the wrong dose of the medication." B. "Furosemide (Lasix) 80 mg by mouth administered." C. "A double dose of furosemide was given to the client." D. "Furosemide 80 mg given to the client instead of 40 mg."

B. "Furosemide (Lasix) 80 mg by mouth administered." Rationale: When completing an incident report, the nurse should state the facts clearly. The nurse avoids documenting subjective data, including assumptions and opinions about what occurred, and avoids assigning blame. Furthermore, the nurse avoids documenting to any wrongdoing. Therefore, option 2 is the only correct option.

The nurse is working with parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the nurse knows that the first step is: A.Exploring reasonable courses of action B. Collecting all available information about the situation C. Clarifying values related to the cause of the dilemma D. Identifying people who can solve the difficulty

B. Collecting all available information about the situation

The nurse finds the client sitting on the floor, ensures the client's safety, completes an incident report, and notifies the health care provider of the incident. What should the nurse implement next? A. Staple the incident report in the client's medical record. B. Document the client events and follow-up nursing actions. C. Provide a copy of the incident report to the provider and family. D. Document in the client's medical record that the nurse sent a copy of the report to risk management.

B. Document the client events and follow-up nursing actions. Rationale: The nurse documents the incident completely and objectively in the client's record to communicate client data to the health care team. The incident report is a confidential, privileged, and internal document used to improve client safety and quality of care and therefore should not be copied, stapled, or placed in the chart. Furthermore, the nurse avoids referring to the incident report in the client's record, such as recording that the incident report has been sent to another department. These actions are necessary because any mention of an incident report in the medical record allows the plaintiff's attorney access to the document through discovery

The nurse administers digoxin (Lanoxin) 0.25 mg instead of the prescribed prescription of 0.125 mg. The nurse discovers the error while charting the medication. The nurse completes an incident report and notifies the health care provider of the incident. Which additional action should the nurse take? A. Gives the client a copy of the incident report B. Documents the incident in the client's record C. Places the incident report in the client's record D. Makes a copy of the incident report and sends it to the health care provider's office

B. Documents the incident in the client's record Rationale: The incident report is not a substitute for a complete entry in the client's record concerning the incident and, therefore, that is what the nurse should do. The incident report is confidential and privileged information. It should not be copied or placed in the chart or have any reference made to it in the client's record. A copy of the incident report is not given to the client; however, the client should be informed of the error, and this is usually done by the client's health care provider. It is the health care provider's responsibility to sign the incident report before it is sent to the risk-management department. A copy should not be made or sent to the health care provider's office.

The student nurse is preparing a list of safety measures for a client who is using oxygen in the home. The registered nurse determines the student needs further teaching if which incorrect measure is placed on the list? A. Stay at least 10 feet away from open flames while using oxygen. B. It is all right to be near someone who is smoking a cigarette while using oxygen. C. Leave a space between the oxygen concentrator and the walls or corners of the room. D. The oxygen should not be turned up without permission from the health care provider.

B. It is all right to be near someone who is smoking a cigarette while using oxygen. Rationale: The client should not allow smoking or any type of flame within 10 feet of the oxygen source. The oxygen concentrator is kept slightly away from the walls and corners to permit adequate air flow. The client should follow the oxygen prescription exactly and not change the dose without consulting the health care provider.

The nurse manager is reviewing with the nursing staff the purposes for applying wrist and ankle restraints to a client. The nurse manager determines that further education is necessary when a nursing staff member states that which is an indication for the use of a restraint? A. Limit movement of a limb. B. Keep the client in bed at night. C. Prevent the violent client from injuring self and others. D. Prevent the client from pulling out intravenous lines and catheters.

B. Keep the client in bed at night. Rationale: Wrist and ankle restraints are devices used to limit the client's movement in situations when it is necessary to immobilize a limb. Restraints are not applied to keep a client in bed at night and should never be used as a form of punishment. Restraints are applied to prevent the client from injuring self or others; pulling out intravenous lines, catheters, or tubes; or removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. A health care provider's prescription is required for the use of restraints, and state and agency procedures are always followed when restraints are used.

An automobile accident victim is admitted to the intensive care unit with a medical diagnosis of increased intracranial pressure. What should the nurse do to maintain the client's rights? A. Keep accurate and current medical records. B. Maintain confidentiality and the client's dignity. C. Incorporate available resources in the plan of care. D. Collaborate with other health care team members on discharge planning.

B. Maintain confidentiality and the client's dignity. Rationale: Maintaining confidentiality and the client's dignity is a component of the client's rights. Option 1 addresses documentation issues. Option 3 addresses safety and other issues. Option 4 addresses case management functions for discharge planning. Although these are appropriate nursing interventions, they are not directly related to client rights.

A staff nurse is walking to lunch in the main corridor of the hospital when a code pink is announced. What should the staff nurse do? A. Go directly to the obstetrics unit to offer assistance as required. B. Observe people in the area who are carrying oversized coats or large bags. C. Quickly move to the hospital entrance and check each person who leaves. D. Contact the charge nurse of the nursery to obtain details.

B. Observe people in the area who are carrying oversized coats or large bags. Rationale: When an infant abduction is announced, every hospital employee is responsible for looking for anyone who could be concealing a baby. Oversized coats and large bags should be suspected and reported. Hospital security will move to exits to inspect anyone who is leaving. The OB unit doors will be locked. Calling the nursery is pointless.

A client has been placed on contact precautions. What is the appropriate nursing intervention to prevent the spread of infection? A. Restrict all visitors. B. Perform meticulous hand washing frequently. C. Wear a mask and gown for all client contacts. D. Wear sterile gloves for all contacts with the client.

B. Perform meticulous hand washing frequently. Rationale: When the client is on contact precautions, meticulous hand washing frequently is necessary. All visitors do not need to be restricted from visiting if they are instructed in the measures to prevent infection. A mask is not necessary for contact precautions, a mask is necessary for respiratory precautions. Sterile gloves are not required, although clean gloves should be worn.

When using a fire extinguisher, the hose is aimed at the: A. area around the flame. B. base of the flame. C. middle of the flame. D. top of the flame.

B. base of the flame. The Occupational Safety and Health Administration (OSHA) states that the fire extinguisher nozzle should be aimed at the base of the fire. Remember to use the PASS technique: Pull, Aim, Squeeze, Sweep. Your facility will provide training on fire emergencies every year.

The nurse professor is presenting a lecture on disasters to a group of nursing students. Which statement by one of the students indicates that the teaching has been successful? A. "Disasters are only internal." B. "Disasters are only external." C. "The disaster response plan should be activated when the number of casualties expected exceeds the usual resource capabilities." D. "The disaster response plan should be activated only when the number of expected casualties is low and can be easily handled by the local health care facility."

C. "The disaster response plan should be activated when the number of casualties expected exceeds the usual resource capabilities." Rationale: Both internal and external disasters can result in many casualties. An accurate statement by the student is that "the disaster response plan should be activated when the number of casualties expected exceeds the usual resource capabilities." It would be incorrect for the student to say that the disaster response plan should be activated only when the number of expected casualties is low and can be easily handled by the local health care facility; in this situation, it is not necessary to activate the plan. Disasters can be internal or external.

The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions does the nurse institute for this client? A. Enteric precautions B. Droplet precautions C. Contact precautions D. Airborne precautions

C. Contact precautions Rationale: Contact precautions include standard precautions and require the use of barrier precautions such as gloves and goggles. Contact precautions are used for clients who have diarrhea, draining wounds, or methicillin-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through inanimate objects or surfaces that the pathogen has contaminated, such as instruments, linens, dressing materials, or hands. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Droplet and airborne precautions are used if the organism is transmitted via the respiratory tract.

A registered nurse (RN) on the night shift assists a staff member in completing an incident report for a client who was found sitting on the floor. Following completion of the report, the RN intervenes if the staff member prepares to take which action? A. Notify the nursing supervisor. B. Ask the unit secretary to telephone the health care provider. C. Document in the nurses' notes that an incident report was filed. D. Forward the incident report to the Continuous Quality Improvement Department.

C. Document in the nurses' notes that an incident report was filed. Rationale: Nurses are advised not to document the filing of an incident report in the nurses' notes for legal reasons. Incident reports inform the facility's administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences in the future. Incident reports also alert the facility's insurance company to a potential claim and the need for further investigation. Options 1, 2, and 4 are accurate interventions.

A patient is admitted to the unit with an order for seizure precautions. Which action is most appropriate? A. Serve the client's food in paper and plastic containers. B. Ensure that soft limb restraints are applied to upper extremities. C. Maintain the client's bed in the lowest position. D. Move the client to a room closer to the nurses' station.

C. Maintain the client's bed in the lowest position. To protect a client with a known or suspected seizure disorder, the bed should be kept in the lowest position, decreasing the chance of injury from falling to the floor during seizure activity.

The nurse understands that incident reports allow the agency to analyze adverse client events by which outcome? A. Supplying supervisors with objective information for performance reviews B. Providing a method of reporting injuries to local, state, and federal agencies C. Reviewing quality care and determining potential risks for injury to the client D. Determining the effectiveness of nursing interventions in relation to outcomes

C. Reviewing quality care and determining potential risks for injury to the client Rationale: Proper documentation of unusual occurrences, incidents, and accidents, as well as the follow-up nursing actions, allow the nursing department and the agency administration to review the quality of care and determine potential risks. Supervisors document the nurse's performance on evaluation documents. Because incident reports are internal documents, they are not used to notify government or regulatory agencies. Quality surveys and nursing research are used to determine the effectiveness of nursing interventions.

The staff nurse is caring for a client with a head injury who is restless and is pulling at the intravenous line. The client's health care provider does not want to sedate the client, and the family has requested that the client not be restrained. Which is the most appropriate action by the nurse? A. Ask a family member to sit with the client. B. Ask a nursing assistant to monitor the client. C. Stay with the client and consult with the nurse manager about the situation. D. Tell the family that the application of wrist restraints is critical to prevent injury to the client.

C. Stay with the client and consult with the nurse manager about the situation. Rationale: The nurse needs to stay with the client and consult with the nurse manager about the situation. It may be necessary for the nurse manager to contact the supervisor to obtain an additional staff member or a trained sitter to care for the client. It is inappropriate to ask a family member to sit with the client. A nursing assistant is not trained to monitor for increased intracranial pressure (ICP). Because the client has a head injury, a major concern is the development of increased ICP. The application of restraints may agitate the client, causing further restlessness and thus increasing ICP.

When responding to the call bell, the nurse finds the client lying on the floor. After a thorough assessment and appropriate care, the nurse completes an incident report. What information should be included? A. The client fell out of bed. B. The client climbed over the side rails. C. The client was found lying on the floor. D. The client was restless and got out of bed.

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

The nurse has been assigned to care for a client recovering at home from a disabling lung infection. While obtaining a nursing history, the nurse learns that the infection is probably the result of human immunodeficiency virus (HIV) contracted through homosexual activity. The nurse is morally opposed to homosexuality and cannot care for the client. The nurse then leaves the client's home. Which is acceptable regarding the nurse's actions? Select all that apply. A. The nurse has the moral right to leave the client's home at any time. B. The nurse has a legal right to inform the client of any barriers to providing care. C. The nurse has a duty to protect self from client care situations that are morally repellent. D. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner. E. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.

D and E Rationale: The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. Refusal to provide care may be acceptable if that refusal does not put the client's safety at risk and the refusal is primarily associated with religious objections, not personal objection to lifestyle or medical diagnosis. There is no legal obligation to inform the client of the nurse's personal objections to the client. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing nor allowing harm to befall the client).

A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of: A) a code blue alert B) a disaster medical assistance team C) the local police and fire department D) the hospital's emergency response plan.

D) the hospital's emergency response plan.

A community health nurse has provided fire safety instructions to a group of individuals who are part of a disaster response team. Which statement by a group member indicates a need for further instructions? A. "Flames should be doused with water." B. "A blanket or another cover can be used to smother the flames." C. "The victim may be rolled on the ground to extinguish the flames." D. "Keep the victim in a standing position so flames won't spread to the other parts of the body."

D. "Keep the victim in a standing position so flames won't spread to the other parts of the body." Rationale: The victim should be placed or kept in a supine position because flames may otherwise spread to other parts of the body, causing more extensive injury. Flames can be extinguished by rolling the client on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water.

A client receives meperidine (Demerol) by the intramuscular (IM) route. Thirty minutes after receiving the medication, the client develops signs of an allergy to the medication. The client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client, contacts the health care provider, and begins to document on an incident report. Which information should the nurse accurately document? A. "The client had an allergic reaction to the meperidine." B. "The health care provider was notified because the client developed a rash after receiving meperidine." C. "The client apparently is allergic to meperidine as noted by a temperature of 101° F, warm and flushed skin, and a rash on the chest and back." D. "Thirty minutes after receiving meperidine, the temperature was 101° F., the client's skin was warm and flushed, and a rash was noted on the chest and back; the health care provider was notified."

D. "Thirty minutes after receiving meperidine, the temperature was 101° F., the client's skin was warm and flushed, and a rash was noted on the chest and back; the health care provider was notified." Rationale: The nurse should document relevant information in an accurate, complete, and objective form. Option 1 does not exemplify objective data. Although option 2 expresses accurate data, it is incomplete. Option 3 makes an interpretation about the occurrence.

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which should be the initial action by the nurse who observed the error? A. Contact the supervisor. B. Complete an incident report. C. Document the error in the client's record. D. Ask the nurse if he or she intends to report the error.

D. Ask the nurse if he or she intends to report the error. Rationale: The initial action by the nurse who observed the error would be to ask the nurse if he intends to report the error. To ensure client safety, all errors need to be reported. The client also needs to be assessed immediately. An incident report needs to be completed by the nurse who administered the incorrect medication. The appropriate documentation also needs to be made in the client's record by the nurse who administered the incorrect medication. If the nurse who made the error indicates that the error will not be reported, then it may be necessary to contact the supervisor.

In the United States, access to health care usually depends on a client's ability to pay for health care, either through insurance or by paying cash. The client the nurse is caring for needs a liver transplant to survive. This client has been out of work for several months and does not have insurance or enough cash. A discussion about the ethics of this situation would involve predominantly the principle of: A. Accountability, because you as the nurse are accountable for the well being of this client B. Respect of autonomy, because this client's autonomy will be violated if he does not receive the liver transplant C. Ethics of care, because the caring thing that a nurse could provide this patient is resources for a liver transplant D. Justice, because the first and greatest question in this situation is how to determine the just distribution of resources

D. Justice, because the first and greatest question in this situation is how to determine the just distribution of resources Justice refers to fairness. Health care providers agree to strive for justice in health care. The term often is used during discussions about resources. Decisions about who should receive available organs are always difficult.

A 50-year-old blind and deaf patient has been admitted to your floor. As the charge nurse, your primary responsibility for this patient is? A. Let others know about the patient's deficits B. Continuously update the patient on the social environment C. Communicate with your supervisor about your patient safety concerns D. Provide a secure for environment for the patient

D. Provide a secure for environment for the patient

The nurse must place a wrist restraint on a client. The client tells the nurse that he does not want to wear the restraint. Which is the best nursing action to implement at this time? A. Sedate the client first. B. Apply the wrist restraint. C. Contact the client's family. D. Reconsider alternative measures.

D. Reconsider alternative measures. Rationale: Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family and a prescription is obtained from the health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.

In the role as a caregiver, the nurse's primary responsibility is to assess the client's ability to do which action? A. Protect self. B. Set his or her own goals. C. Decide the best approach for care. D. Restore physical, emotional, and social well-being.

D. Restore physical, emotional, and social well-being. Rationale: A primary role of the caregiver is to assess the client's ability to restore well-being. Options 1, 2, and 3 identify the nurse's role as a client advocate.

Successful ethical discussion depends on people who have a clear sense of personal values. When many people share the same values it may be possible to identify a philosophy of utilitarianism, with proposes that: A. The value of people is determined solely by leaders in the Unitarian church B. The decision to perform a liver transplant depends on a measure of the moral life that the client has led so far C. The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician D. The value of something is determined by its usefulness to society

D. The value of something is determined by its usefulness to society