Management of Care-Passpoint
A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? the nurse the surgeon the anesthesiologist the social worker
It is the role of the surgeon or the person performing the procedure to obtain the informed consent. This consists of informing the client about the procedure, the risks of treatment, the side effects, other types of treatments available, and the effects without the procedure. Nurses, anesthesiologists, and social workers do not obtain informed consent.
When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be allowing family members to visit a newly admitted client. ambulating the client in the hallway. administering pain medication. placing wrist restraints on the client.
In Maslow's hierarchy of needs, pain relief is on the first layer. Love and belonging, as in allowing family members to visit, are on the third layer. Activity, as in ambulation, is on the fifth layer. Safety, as in placing wrist restraints on the client, is on the second layer.
The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who has a newly applied long-leg plaster cast. What should the nurse tell the UAP about proper care of the cast while it is drying? "Keep the cast covered with a sheet to protect it while drying." "Turn the client every 2 hours to promote even drying of the cast." "Use a blow dryer on the cast for 15 minutes every 2 hours until the cast is dry." "Carefully use your fingers to lift the cast and reposition the legs."
The client should be repositioned every 2 hours to promote even drying of the cast.The cast should be kept uncovered while drying to allow air to circulate around the cast and prevent heat from building up within it.It takes 24 to 72 hours for a plaster cast to dry; using a blow dryer may cause a heat burn and does not reduce the time for the cast to dry.The palms of the hands, not the fingers, should be used to move a drying cast in order to prevent indentations that can cause pressure points to develop.
A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because nurses are highly vulnerable to criminal and civil prosecution in the course of their work. nurses interact with clients and families from diverse cultural and religious backgrounds. nursing practice involves numerous interactions between laws and individual values. nurses are responsible for carrying out actions that have been ordered by other individuals.
A code of ethics is necessary to guide nurses' conduct especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.
A 15-year-old client who is 26 weeks pregnant has been admitted to the labor and delivery unit with reports of abdominal pain. Her parents want to speak with a nurse about her condition. How should the nurse respond? "I'll need a signed consent from your daughter to give you medical information." "The health care provider can give you more information without consent." "She will be OK. It's just a stomachache." "She is experiencing Braxton Hicks contractions and is too young to understand the difference between these contractions and labor pains."
A pregnant minor is emancipated from her parents so she can make decisions for herself and her baby. Therefore, the client's right to confidentiality means that neither the nurse nor the health care provider may divulge medical information without a signed consent.
The nurse is reviewing the client's medication orders and finds an order reading, Alprazolam 1.0 mg PO every 4 hours prn anxiety. What action(s) should the nurse take? Select all that apply. Call the healthcare provider to clarify the order. Give the medication when the client wants it. Hold the medication. Start the medication immediately. Call the pharmacy.
An improper placement of a decimal point can result in a serious medication error. Trailing zeros should not be used with whole numbers as the order could be misread as Alprazolam 10 mg PO every 4 hours prn anxiety. The nurse should hold the medication, and call the physician to clarify the entire order.
A client whose blood type is A- gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important? ensuring that the client understands the procedure and signs a consent for the vaccination choosing an injection site that isn't tender instructing the client that she won't need an additional vaccination after her next pregnancy documenting administration of the drug in the client's chart
Before Rho(D) immune globulin administration, the nurse must educate the client about the medication, and the client must sign consent. The nurse should document the procedure after giving the injection. The nurse should advise the client that Rho(D) immune globulin administration will be needed after every pregnancy. Choosing an injection site that isn't tender isn't a priority.
Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception. Which is a benefit of this method of documentation? It documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.
Charting by exception provides quick access to abnormal findings because it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method which is used in the progress notes when referring to interventions and the client's responses.
A nurse is caring for a client on life support in the cardiac care unit. The client's family, which is strongly religious, is unable to unanimously decide to remove life support. What should the nurse do? Select all that apply. Notify the hospital's ethics committee of the ethical dilemma. Ask the family to leave the unit to pray for a unified decision. Request pastoral services to assist the family in this decision. Supply the family with information and pamphlets on funeral services. Initiate family discussions toward what the client would have wanted.
Ethics committees are a valuable resource for reviewing difficult cases and helping ensure a careful and unbiased decision when advocating for the client. Since the family is religious it is appropriate to request pastoral services or ask them if they would like you to call their spiritual advisor. Therapeutic communication with the family about their loved ones wishes is appropriate and often helpful. It is not therapeutic to ask families to leave to pray or force a unified decision. It is inappropriate to provide pamphlets on funeral services to a family struggling with end of life decisions.
A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations? Contact the child's health care provider (HCP) during office hours. Review nationally published immunization guidelines. Read each vaccine's manufacturer's insert. Ask a local pharmacist on duty.
National advisory committees on immunization practices review vaccination evidence and update recommendations yearly. Current vaccination catch-up schedules are readily available on their websites. The lack of vaccinations is a strong indicator that the child probably does not have a HCP. Even if the client had a provider, however, that person might be difficult to reach on a weekend during the timeframe of a vaccination clinic. If consulted, the pharmacist would most likely have to review the latest guidelines that are equally available to the nurse. Reading each of manufacturer's inserts for multiple vaccines would be time consuming, and synthesis of the information could possibly lead to errors.
A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, "He is rude. His patients always end up with infections." The nurse is at risk of being accused of what? libel slander negligence assault
Slander involves words communicated verbally to a third party that harm or injure the personal or professional reputation of another person. The other options do not define the situation described in the question.
A charge nurse is making assignments for a team that includes two registered nurses (RNs) and one unlicensed assistive personnel (UAP). One client requires a nurse to perform several complex procedures. The charge nurse should: assign each complex procedure to a different RN. assign the same number of clients to each RN, but with lower acuity. assign fewer clients to the RN managing this client's care. assign additional UAP to assist the RN.
The charge nurse assigns fewer clients to the RN who will be taking care of the client with high-acuity needs. Even though the RN would be assigned clients with lower acuity in addition to the client with high acuity, the RN will be planning care for more clients.Dividing the care for the high acuity client among several RNs increases the risk of error.The UAP will not be able to perform the complex procedures required for the high-acuity client.
A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first? the client with anorexia, weight loss, and night sweats the client with crackles and fever who reports pleuritic pain the client who had difficulty sleeping, daytime fatigue, and morning headache the client with unilateral leg swelling who reports anxiety and shortness of breath
The client who reports anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism.
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider? furosemide fresh frozen plasma IV rate increase dextrose 5%
The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, normal saline, or albumin.
The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. What should the nurse manager of the operating room do? Require the nurse to do this assignment. Change the assignment and record the behavior on the nurse's evaluation. Change the assignment without comment. Change the assignment to circulate but have the nurse prepare the equipment.
The nurse should not be required to participate in an abortion if it contradicts the nurse's religious beliefs. The behavior should not be reflected negatively on the nurse's evaluation. Preparing equipment and supplies for the case may be viewed as the same as circulating for the case. The nurse has a right not to participate in an abortion unless it is an absolute emergency and no one else is available to care for the client.
What should the nurse do when transcribing a verbal order from a health care provider? Select all that apply. Read the order back to the health care provider. Document the date the order was given. Have the health care provider sign the order within 24 hours. Record the order in the client's medical chart. Use abbreviations when transcribing the verbal order.
The nurse should read the order back to the health care provider to verify accuracy. The date the order was issued needs to be transcribed. The health care provider should not sign the order within 24 hours; it needs to be signed as soon as possible. The nurse should record the order in the client's medical chart. The nurse should not use abbreviations when transcribing the verbal order. The Joint Commission discourages the use of abbreviations.
A community health nurse is working disaster relief immediately after a flood. Which interventions would be a priority following this crisis? Select all that apply. finding safe housing for the survivors organizing counseling for the survivors providing vaccinations for childhood diseases securing physical care screening for waterborne diseases
The nurse would prioritize care according to Maslow's hierarchy of needs. Physical needs, safe housing, and prevention of disease would be the priority. Counseling would come after the physical needs were met. Vaccinations for childhood diseases would not be appropriate. The clients would need to be vaccinated for tetanus if not up to date.
A client experiencing alcohol withdrawal reports being upset about going through detoxification. Which goal is the priority for this client? committing to a drug-free lifestyle working with the nurse to remain safe drinking plenty of fluids on a daily basis making a personal inventory of strengths
The priority goal is for client safety. Although drinking enough fluids, identifying personal strengths, and committing to a drug-free lifestyle are important goals, the nurse's first priority must be to promote client safety.
A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained? "This implanted defibrillator will protect me against some of those bad rhythms my heart goes into." "I wonder if there is any other way to prevent these bad rhythms." "The physician will make a small incision in my chest wall and place the generator there." "A wire from the generator will be attached to my heart."
The client wondering if there is another way to prevent the abnormal rhythms indicates that other treatment options weren't discussed with the client. Before participating in a clinical trial, the client must be informed of all other available treatment options. The other statements about implantable cardioverter-defibrillators are all true.
A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding? pulse pressure pulse deficit pulse rhythm pulsus regularis
The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the difference between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.
While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: report this to the nursing supervisor immediately. report this to the head nurse in the morning. ask the nurse if she has been drinking. assess the nurse's behavior for signs of intoxication.
This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed until the head nurse is available on the day shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.
An infant who has been in foster care since birth requires a blood transfusion. Who will the nurse approach to give written, informed consent for the procedure? the foster mother the social worker for the foster home a Child Protective Services representative the nurse manager
When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social worker, the nurse, and the nurse manager have no legal rights to give consent in this scenario. Child Protective Services would become involved only if there was a disagreement between the healthcare provider's recommendation and the foster mother's willingness to consent to treatment.
Nurses who provide care in a large, long-term care facility use charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawbacks? vulnerability to legal liability because the nurse's safe, routine care is not recorded increased workload for nurses to complete necessary documentation failure to identify and record problems and associated interventions significant differences in charting among nurses from lack of standardization
A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality and safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation and both standardization of charting and identification of client-specific problems are possible within this documentation framework.
A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose? a client's HIV status to family members a client's pancreatic cancer diagnosis to the client's partner a taxi driver's diagnosis of an uncontrolled seizure disorder to the licensing agency a client who is 32 weeks pregnant with twins and legally separated to the spouse
The nurse may lawfully disclose confidential information about a client when the welfare of others is at stake. The nurse is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder because it's in the best interest of the public's and client's safety. Confidentiality of HIV testing is required. Disclosing a client's cancer diagnosis to a significant other or pregnancy to a legally separated partner do not affect the welfare of person.
A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error? Assess the patient for the medications' effects. Notify the charge nurse of the error. Call the practitioner of the patient who received the wrong medications. Have the nursing assistant complete a set of vital signs.
The nurse should immediately assess the client who received the wrong medications. This assessment should include potential allergies to the medications and the side effects of the medications. The nurse should then notify the practitioner and the charge nurse. An incident report should be completed and submitted as directed by the facility's policy. The nurse should complete a set of vital signs with the assessment of the client.
A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply. Maintain fluid intake at fluid maintenance standards. Teach diaphragmatic, pursed-lip breathing. Administer low-flow oxygen as needed. Maintain the client in a supine position as much as possible. Encourage alternating client activity with rest periods. Teach the use of postural drainage and chest physiotherapy.
Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because a client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows clients to perform activities without distress. If the client has difficulty mobilizing copious secretions, the nurse would teach the client and family members how to perform postural drainage and chest physiotherapy. Fluid intake would be increased to 3,000 ml/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client would be placed in high Fowler's position to improve ventilation.
A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first? Initiate fetal and contraction monitoring. Start the intravenous infusion. Obtain the urine specimen. Administer betamethasone.
The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other orders. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if ordered.
The nursing assistant reports to the charge nurse in a skilled nursing facility that a client wants to stay in bed. After the second day of staying in bed, the nurse assesses the client's vital signs and finds the blood pressure to be below the client's norm, and the nurse withholds the client's medications. A visiting family member asks what is happening. How should the nurse best explain this change in condition? Select all that apply. "I do not know why this happening." "It must be the flu because it is the flu season." "Older people often feel weak and tired." "I will report this change of activity to the healthcare provider." "Do you want to send your family member to the hospital to be evaluated?"
The nurse will need to explain to the family member that the change in activity will be reported to the HCP and the client can be transported to a hospital for evaluation. The nurse needs to communicate to the family member and provide action related to the client's change.
A 9-year-old child presents to a school nurse and reports arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate? Arrange for the child to speak with the school psychologist as soon as possible. Arrange for a meeting with the nurse, psychologist, school administrators, and the child's parents. Contact the authorities immediately. Contact an ambulance to transport the child to the emergency department.
When a nurse suspects abuse, the nurse must contact the authorities immediately. Although speaking with the school psychologist may be helpful, the nurse should not delay contacting the authorities. A family meeting might provide additional information, but the nurse must allow the authorities to investigate suspected abuse before confronting the child's parents. Because the child is not in imminent distress, there is no need for an ambulance.
