Legal/ Management NCLEX

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first

A client on a ventilator

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

The nurse is caring for a client who has refused to take an oral medication. The nurse tells the client that the nurse will hold the client down and give the medication by injection if the client doesn't take the oral medication. The nurse then takes the client's bathrobe so the client will have to remain in his room. Which intentional torts has this nurse committed? Select all that apply

Assault False imprisonment

The nurse knows that litigation involving nurses is common because of which reasons? Select all that apply.

Clients are better educated about health care. Clients are better informed about their rights. Clients have a higher expectation about the care they receive.

Which guidelines should the nurse follow when performing narrative documentation? Select all that apply.

Date and time entries. Sign and title each entry. Avoid judgmental and evaluative statements. Do not leave blank spaces on documentation forms.

The nurse is aware that the ethical philosophy of deontology is composed of which "right-making characteristics"? Select all that apply.

Justice Truthfulness Fidelity to promises

The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process?

To compare a client's medication prescriptions to all of the medications the client is taking at home

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

"I have a legal obligation to report this type of abuse."

The nurse educator determines that a newly hired licensed practical nurse (LPN) in a local hospital demonstrates an accurate understanding of professional liability insurance when which statement is made?

"I should obtain my own malpractice insurance."

The nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the accident. Which is accurate regarding the nurse's immunity from this suit?

A Good Samaritan law will protect the nurse.

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection

A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first?

A client with a fever who is diaphoretic and restless

A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign four clients and has a licensed practical nurse (LPN) and three unlicensed assistive personnel (UAP) on a nursing team. To which client should the nurse assign the LPN?

A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?

A postoperative client who develops a cough and a fever

The nurse is assisting in planning client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a profoundly developmentally disabled child to eat lunch

The nurse is assigned to care for a newly admitted client and is reviewing the health care provider's prescriptions. The nurse notes that the health care provider has prescribed a medication dose that is twice the amount that the client reports taking before admission. Which nursing action is appropriate?

Consult with the registered nurse (RN).

Following an airplane crash that had only a few survivors, the nurse should anticipate which survivor responses to stress? Select all that apply.

Difficulty sleeping Feeling vulnerable Feeling blame or guilt Feeling numb or in disbelief

A 7-year-old child is admitted to the pediatric unit with acute exacerbation of asthma due to infection. The health care provider has written the following prescriptions. In which priority order should the nurse implement the prescriptions? Arrange the actions in the order that they should be performed. All options must be used.

High-Fowler's position O2 via nasal cannula at 2 L/min Erythromycin ethylsuccinate (EryPed) 200 mg orally every 6 hours Chest x-ray Clear liquids PO as tolerated

The nurse posted a comment on a social media site that was unflattering to another nurse. Which accusations can the second nurse bring against the first nurse? Select all that apply.

Libel Defamation

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). After appropriately charting in the medication administration record, which action should the nurse take?

Make a notation regarding the client's refusal in the nurse's notes.

The nurse was assigned to care for five clients and spent most of the day caring for one of these clients who had just returned from surgery. The nurse did not ask for assistance and did not regularly check on the other clients. During the day, one of the nurse's other clients got out of bed without calling for assistance and fell, breaking his arm. Which possible charges could this nurse face with this situation? Select all that apply.

Negligence Malpractice Abandonment of care

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of the tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task.

Which are the best ways for the nurse to avoid malpractice? Select all that apply.

Perform interventions in a timely manner. Document assessments and procedures completed. Know current nursing literature in their area of practice.

The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility?

Report the case in which the abuse is suspected.

The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?

Respiratory status

The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used.

The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching

The nurse is observing a an unlicensed assistive personnel (UAP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed?

The UAP stresses words by overenunciating them when speaking.

The nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to an unlicensed assistive personnel (UAP). The UAP notifies the nurse that the client's vital signs are elevated and the client is complaining of pain and dyspnea. Which is appropriate regarding the nurse's next action?

The nurse checks the client and gathers additional data before calling the health care provider.

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which data would indicate a negative variance?

The presence of dysrhythmias in a client with a myocardial infarction

After pleading for information, a visitor learns from the nurse that his friend (the client) has died from human immunodeficiency virus (HIV). Inadvertently, the visitor informs the client's family about the client's HIV diagnosis. Which is the most serious potential consequence of possible damages caused by these events?

The state convicts the nurse for invasion of privacy.

A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of his leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client?

Use of padded restraints to immobilize the limb

The nurse is working with a 21-year-old client who has a family history of Huntington's disease and asks for information about the advantages of genetic testing. Which responses by the nurse is best?

"Genetic testing will help you make decisions about having children." "Retirement issues might be easier to plan if you know the results of the test." "Knowing if you have the disease will allow you to make plans about your career."

The nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for what evidence that supports this information?

A judicial decision in a court of law

The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern?

Discourage the racial comments.

The nurse is aware that which criteria are necessary for a situation to be classified as malpractice? Select all that apply.

The client sustained an injury. The nurse owed a duty to the client. The nurse did not carry out a duty to a client. The client's injury was caused by the nurse's failure to duty.

The nurse is present at a disaster scene and is participating in the triage of victims. Which color tag should be assigned to a victim with evidence of open pneumothorax?

Red

A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action?

Notify the health care provider of the client's request.

The nurse has just been licensed and has begun to practice in an acute health care facility. The nurse knows that which nursing specialties will require more specific defined standards of care and skills? Select all that apply.

Nurse-midwives Nurse-anesthetists Intensive care unit (ICU) nurses

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which action in the care of this client?

Obtain telephone consent from the family member witnessed by two persons.

The nurse manager asks a licensed practical nurse to work on her day off because of a short-staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. Which response by the licensed practical nurse to the nurse manager is assertive?

"I have planned to take the day off and will not be able to work on that day."

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 response to the client is appropriate?

"I will call the nursing supervisor to seek assistance regarding your request."

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept?

"It represents a primary health prevention focus managed by a single case manager."

The new nurse graduate asks another nurse about the need to obtain professional liability insurance. Which is the most appropriate response by the nurse?

"Nurses need to have their own malpractice insurance."

The nurse is presenting a lecture on disasters and posttraumatic stress disorder (PTSD) to a group of new unlicensed assistive personnel (UAP). Which statements by the UAP indicate that teaching has been effective? Select all that apply.

"PTSD can potentially last a lifetime." "Clients can be easily startled and have difficulty sleeping." "Flashbacks occur, causing the client to relive the experience."

The nurse has received the following client assignments. In which priority order should the clients be seen based on the clients' needs? Arrange the clients in the order that they should be seen. All options must be used.

1. A client with an arm cast for 1 day complaining of excruciating pain in the casted arm 2. A client being transferred from the intensive care unit (ICU), 1 day post-coronary artery bypass graft surgery, complaining of incisional pain 3. A client admitted 4 days ago following a myocardial infarction (MI), complaining of a headache 4.A client 1 day postoperative following an open reduction and internal fixation to the wrist, complaining of pain localized to the pin sites 5. A client who is 3 days postoperative abdominal surgery, complaining of pain when taking a deep breath

A nurse working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client should the nurse collect data on first?

A client who was complaining of severe back pain on the previous shift

The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom?

A few individuals such as the board of directors

A client had a colon resection. A Salem tube was in place when a regular diet was brought into the client's room. The client did not want to eat solid food and asked that the health care provider be called. The nurse persisted in the belief that the solid food was the correct diet. The client ate two meals and subsequently had additional surgery due to complications. The nurse understands that the determination of negligence in this situation is based on what?

A duty existed and it was breached

The nurse is planning the client assignments for the day. The assignment that the nurse communicates to the unlicensed assistive personnel (UAP) includes which clients? Select all that apply.

A 9-year-old client with cystic fibrosis who requires assistance with toileting A 12-month-old client admitted 3 days ago with respiratory syncytial virus (RSV) who requires a bath A 10-month-old admitted for spasmodic laryngitis who is scheduled for discharge the following day who requires feeding

The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first?

A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count

The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first?

A client who was admitted during the night because of a severe exacerbation of asthma

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management

Which is a recommended guideline for safe computerized charting?

Accidental deletions from the computerized file need to be reported to the nursing manager or supervisor.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action?

Activate the agency emergency response plan.

A client with a diagnosis of cystitis has an indwelling urinary catheter and is being cared for by an unlicensed assistive personnel (UAP). The nurse observes the UAP care for the client and intervenes if the UAP performs which action?

Allows the drainage tubing to rest under the leg

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel?

Answering the call light promptly after the enema has been given

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 would be the initial action by the nurse who observed the error?

Ask the nurse if he or she intends to report the error.

The nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is angry with the assignment because of a belief that the assignment is more difficult than the assignment delegated to other nurses on the unit. The nurse should carry out which action?

Ask the nurse manager of the neurological unit to discuss the assignment.

The nurse is planning the client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a child who is profoundly developmentally disabled to eat lunch

Which factors should the nurse consider when developing a critical incident stress debriefing (CISD) plan for employees of a level 1 trauma center? Select all that apply.

CISD promotes effective coping strategies. CISD occurs in small group settings for staff. CISD may help prevent posttraumatic stress disorder. CISD is only one component of a much larger stress management program.

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 action would be the appropriate initial action by the nurse?

Call the nursing supervisor.

The unlicensed assistive personnel (UAP) who has been employed in a long-term care facility for 8 weeks is consistently 10 to 20 minutes late for work. The UAPs lateness has caused unrest with other staff members in the nursing unit. The UAP is due to receive a 3-month probation evaluation in 1 month. Which is the most appropriate action by the nurse in charge of the nursing unit when dealing with this situation?

Confronting the UAP to discuss the lateness and initiate problem-solving measures

The nurse employed in a long-term care facility calls the health care provider (HCP) regarding a new medication prescription because the dose 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?

Contact the nursing supervisor.

After weeks of witnessing a man's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which criterion does the nurse use to determine if the autopsy can proceed?

Determination by the client's son

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will.

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

The nurse is assisting in developing a plan of action for the emergency department in the event of an internal fire. Which should the nurse include in the plan? Select all that apply.

Direct ambulating clients to walk to a safe location. Remove all clients from danger before attempting to extinguish the fire. Move bedridden clients away from the fire area by use of beds or stretchers.

A pediatric nurse arrives at work and is told to report (float) to the emergency department (ED) for the day because the ED is expecting numerous victims to arrive following a train crash. The nurse has never worked in the ED and is anxious about floating to this area. Which is the appropriate nursing action?

Discuss her anxieties and concerns with the nursing supervisor about floating.

The licensed practical nurse (LPN) enters a client's room and finds the client sitting on the floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and health care provider (HCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Documenting task completion at the end of the day

The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which is accurate regarding immunity from this suit?

Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided.

A client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses the client 15 minutes after administering the medication and reminds the client to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Which issues support the client's malpractice claim? Select all that apply.

Increased risk of hypotension Failure to teach the client adequately Increased need to protect the client Lack of follow-up nursing actions

The nurse is aware that criminal offenses would have which characteristics as opposed to civil offenses? Select all that apply.

It is offensive to society in general. It is detrimental to society as a whole. It involves offenses such as robbery, murder, and assault. It will result in punishment whose purpose is to deter further crimes.

The nurse is aware that the American's with Disabilities Act provides which rights to individuals who are disabled? Select all that apply.

Labels asymptomatic HIV as a disability Protects the privacy of individuals with HIV Prohibits discrimination in employment and public services

An unlicensed assistive personnel (UAP) tells the nurse that she is becoming very frustrated trying to communicate with an older client who is severely hard of hearing and does not have his hearing aid. Which instructions should the nurse recommend to improve communication between the UAP and the client? Select all that apply.

Make sure the environment is well lit. Face the client and speak slowly and clearly. Ask the client to repeat what has been said. Turn the television volume down while communicating.

The licensed practical nurse knows that which items are examples of common law? Select all that apply.

Malpractice Informed consent Client's right to refuse treatment

The nurse shares with a client that violation of a civil law usually results in which type of penalty? Select all that apply.

Monetary fine Public service Replacement of property

The nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is correctly characterized by which statement?

Negligence is defined as the failure to meet established standards of care.

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?

No charge will be made against the RN because the RN's actions are reasonable.

The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest to use?

Providing educational programs, literature, and posters to promote awareness of healthy eating

After reviewing the psychosocial implications following a disaster, the nurse is assigned to care for a client who has just witnessed a mass shooting. Upon obtaining subjective information from the client, which actions should the nurse take? Select all that apply.

Remain calm and reassuring. Convey caring behaviors towards the client. Establish rapport and actively listen to the client.

The nurse suspects that a co-worker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action should the nurse take?

Report the information to a supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

A licensed practical nurse (LPN) is collecting data on a child and notes the presence of old and new bruises on the child's back and legs. The LPN suspects physical abuse and reports the findings to the registered nurse knowing that which action is necessary?

Reporting the case to legal authorities

The licensed practical nurse is considering leaving the nursing profession after caring for multiple clients who have been diagnosed with conditions that have poor outcomes. Which measures would most likely assist the nurse in relieving this distress? Select all that apply.

Share the frustrations at unit multidisciplinary meetings. Engage in ethics discussions with both nurses and other health care practitioners.

The nurse calls the health care provider (HCP) of a client scheduled for a cardiac catheterization because the client has numerous questions regarding the procedure and has requested to speak to the HCP. The HCP is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside the client's room and hears the HCP tell the client in a derogatory manner that the nurse "doesn't know anything." The nurse plans to address the HCP's remark, understanding that the HCP has violated which legal tort?

Slander

The nurse witnesses an accident in which the victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to a victim who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files suit against the nurse who provided care at the scene of the accident. Which accurately describes the nurse's immunity from this suit?

The Good Samaritan laws will protect the nurse if the care given at the scene was not negligent.

A client who had a lung resection for cancer has been told that bone metastasis has occurred. The client is considering megavitamin and diet therapy because the original surgery did not provide a cure. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates which concepts?

The client's right to autonomy and the nurse's obligation to behave ethically

The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?

The tertiary level of prevention

A client receives meperidine (Demerol) by the intramuscular 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 and contacts the registered nurse, who then contacts the health care provider. The nurse completes an incident report and accurately documents which?

Thirty minutes after receiving meperidine, the temperature is 101° F, skin is warm and flushed, and a rash is noted on the chest and back; the health care provider was notified.

The health care provider writes a prescription for the nurse to obtain a consent for a colonoscopy. Which are the nurse's responsibilities to obtain an informed consent? Select all that apply.

To ensure the client is the age of consent To ensure the client is signing voluntarily

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent.

An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected, and emergency surgery is required immediately in order to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse plans to take which best nursing action?

Transport the client to the operating room immediately.

The nurse observes an outburst by a client with a history of schizophrenia, during which the client uses extreme foul language. Which appropriate documentation should the nurse make for this occurrence?

Use quotation marks, exact words, and additional objective information about affect and nonverbal behavior.

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements?

"They are specific guidelines."

The nurse on the day shift is assigned to care for the following six clients. List in order of priority how the nurse should plan to check the assigned clients. Arrange the actions in the order that they should be performed. All options must be used.

1. Client who has a tracheostomy and is on a mechanical ventilator 2. Client who requires before-breakfast insulin 3. Client who is scheduled for a cardiac catheterization at 9:00 am 4. Client who requires medications at 10:00 am 5. Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home 6. Client who is scheduled for physical therapy in the afternoon

Place in correct order the steps the nurse should use to resolve an ethical dilemma. Arrange the actions in the order that they should be performed. All options must be used.

1. Determine if an ethical dilemma exists. 2. Gather necessary information. 3. Clarify values. 4. Verbalize the problem. 5. Identify possible courses of action. 6. Negotiate a plan. 7. Evaluate the plan.

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next?

Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.

A client with chronic obstructive pulmonary disease (COPD) asks the nurse for assistance with preparing a living will. The client tells the nurse that she has not discussed the living will with the family and wanted to make some decisions before discussing the will with the family. Which initial step in preparing this document should the nurse inform the client to do?

Discuss the request with the health care provider.

A vascular surgeon repeatedly asks the nurse to obtain signed consent forms on his surgical clients. The nurse is uncomfortable with obtaining the informed consents and explains this to the surgeon, but the surgeon tells the nurse that she will be reported if the consents are not obtained. The nurse should appropriately manage this situation by taking which action?

Discuss the situation with the nurse manager.

A client has just been treated with cardioversion. The nurse should check which measure first?

Status of airway

The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel?

A client on strict bed rest and a 24-hour urine collection

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse collect data on first?

A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client requiring frequent ambulation with a walker

Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?

A client who says that voices sponsored by the FBI are telling him to stab his roommates

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim should the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which victim should be transported to the hospital first?

A victim with singed nasal and facial hair and difficulty breathing

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

Change the password for entering computer files at least monthly. Shred the printout of the nurse's flowchart at the end of the nurse's shift. Use own user name and password when logging into the computer system.

The nurse is caring for a client who just returned from surgery for repair of a fractured arm. The client complains of severe pain in the arm and also that his hand is feeling numb. The nurse notes that the client's fingers are pale and that the pulse in his arm is very weak. The nurse attempts to contact the surgeon numerous times, but the surgeon does not return the call. Who should the nurse notify at this time? Select all that apply.

Charge nurse Hospital supervisor Surgeon's supervisor

A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN makes which suggestion to the community nurse to direct the group most effectively?

Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem.

A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago at 7:30 am. The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 and is due to eat lunch at noon. List in order of priority the actions that the nurse should take. Arrange the actions in the order that they should be performed. All options must be used.

1. Check the client's blood glucose level. 2. Give the client half a cup of fruit juice to drink. 3. Take the client's vital signs. 4. Retest the client's blood glucose level. 5. Give the client a small snack of carbohydrate and protein. 6. Document the client's complaints, the actions taken, and the outcome.

A group of nurses are reinforcing instructions on health and safety management to survivors of a hurricane before they leave their temporary shelter and return home. Which instructions should the nurses include? Select all that apply.

Boil water for 5 to 10 minutes before drinking. Wash hands with soap and water frequently. Avoid mixing chemicals such as cleaning chemicals. Add 10 to 20 drops of chlorine bleach to a gallon of water before drinking.

A new nurse is employed at a local community hospital and is attending an orientation session. The nurse educator conducting the session asks the new nurse to describe an organization's mission statement. The new nurse appropriately responds with which statement?

It outlines what the organization plans to accomplish.

The nurse is caring for an older adult and knows that an ethical dilemma is most likely to occur in this population because of which issues? Select all that apply.

Limited vision Chronic illness Lack of assertiveness

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which is a characteristic of this type of nursing model of practice?

Nursing staff are led by the nurse when providing care to a group of clients.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

Private room within sight of the nurses' station

The nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which is the appropriate nursing action?

Tell the client that it is necessary to notify the health care provider of the client's request.

A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths?

"They are nursing care plans and use the steps of the nursing process."

When caring for clients, the nurse knows that which ethical philosophies focus on understanding relationships and the use of personal narratives? Select all that apply

Ethics of care Feminist ethics

The licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that which is the initial step in the process of change?

Identify the inefficiency that needs improvement or correction.

The nurse observes that an older male client is confined to his room by his daughter-in-law. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way, and my son needs me to stay here." Which is the best nursing intervention for this situation?

Suggest appropriate resources such as respite care and a senior citizens' center to the client and daughter-in-law.

A nurse lawyer provides an education session to the nursing staff regarding client rights. The nurse asks the lawyer to describe an example that may relate to invasion of client privacy. Which nursing action indicates a violation of client privacy?

Taking photographs of the client without consent

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching

"Mass casualty events do not require an increase in the number of staff that are needed." "A mass casualty event occurs only within the heath care facility and could endanger staff." "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

The nurse 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.

"Mass casualty events do not require an increase in the number of staff that are needed." "A mass casualty event occurs only within the heath care facility and could endanger staff." "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization?

"Beneficiaries are limited to those providers that are participating health care providers for any required health care services."

The nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to an unlicensed assistive personnel (UAP) to attend to the other clients and tells another nurse to call the health care provider immediately. In this situation, the nurse is implementing which leadership style?

Autocratic

The nurse wants to ensure that the emergency department is prepared for a disaster and is creating an action plan for educating the staff. Which actions should the nurse plan in order to adequately prepare the staff? Select all that apply.

Identify specific nursing roles during a disaster. Test the disaster plans before a disaster occurs. Begin educating staff on roles at the time of a disaster. Encourage each nurse to create a personal emergency preparedness plan.

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider that the client had terminal cancer. The emergency department health care provider examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate?

"I will contact the medical examiner regarding your request."

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies which aspect of care as a priority of care?

Actual or life-threatening concerns

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?

Assault

The nurse is assisting in caring for a client with a head injury who is restless and is pulling at the intravenous (IV) 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. The nurse should implement which?

Stay with the client and consult with the nurse manager about the situation.

An adult client is brought to the emergency department by the emergency medical services team after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. With regard to informed consent for the surgical procedure, which nursing action is correct?

Transport the victim to the operating room for surgery.

The nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. What does the nurse determine is a characteristic of this type of nursing model practice?

Nursing personnel are led by an RN leader in providing care to a group of clients.

Place in correct order the steps the nurse should use to resolve an ethical dilemma. Arrange the actions in the order that they should be performed. All options must be used.

Determine if an ethical dilemma exists. Gather necessary information. Clarify values. Verbalize the problem. Identify possible courses of action. Negotiate a plan. Evaluate the plan.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires frequent ambulation

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

"Accountability can be delegated."