NU370 PrepU: Accountability

The nurse is caring for a client who has just died after a long diagnosis of dementia. Which nursing assessment is the priority for documentation? a) "No breathing and no pulse at 0840." b) "Postmortem care completed." c) "Body transported to morgue." d) "Notified the patient's daughter."

a) "No breathing and no pulse at 0840." - The priority documentation is the assessment that indicates the client is dead. The other items can occur and will be documented after establishing that death has occurred.

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: a) Anesthesiologist b) Circulating nurse c) Scrub nurse d) Surgeon

b) Circulating nurse - The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate? a) Discard it in the waste can. b) Do nothing; it can be used again immediately. c) Disinfect it with alcohol swabs. d) Sterilize it by placing it in the autoclave.

c) Disinfect it with alcohol swabs. - Equipment such as stethoscopes, sphygmomanometers, and other assessment tools that are used for clients on contact precautions should be cleaned and disinfected before use on other clients. The other answers are incorrect.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation? a) Report the incidents to the facility's lawyer. b) Remind the residents and family members not to leave valuables unattended. c) Pass the information on to the doctor and the next shift staff. d) Notify the supervisor and call the police.

d) Notify the supervisor and call the police. - The supervisor should be made aware of the situation and the police should be called to investigate the potential theft. The other answers do not advocate for the clients and their families. It is the responsibility of the nurse to take action because the nurse was the person to receive the information. This is known as due diligence.

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? a) Surgeon b) Circulating nurse c) Scrub nurse d) Anesthetist

a) Surgeon - The registered nurse first assistant practices under the direct supervision of the surgeon. The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment. The anesthetist administers the anesthetic medications.

A nurse preparing medication for a client is called away to an emergency. What should the nurse do? a) Have another nurse guard the preparations. b) Put the medications back in the containers. c) Have another nurse finish preparing and administering the medications. d) Lock the medications in a cart and finish them upon return.

d) Lock the medications in a cart and finish them upon return. - Once medications have been prepared the nurse must either stay with the medications or lock them in an area such as the medication cart. The medications should never be left unattended or placed back in their containers. Another nurse cannot administer medications that have been prepared by the first nurse.

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alfa as alternatives to a blood transfusion. Which response by the nurse causes the supervising nurse to plan a review of professional and ethical standards? a) "You should take the unit of blood. It will help you feel better." b) "Do you have all the information you need for informed consent?" c) "Do you have any questions that I can clarify for you?" d) "Tell me how the nurse educator explained the procedure."

a) "You should take the unit of blood. It will help you feel better." - Stating that the client should accept a blood transfusion is a violation of professional and ethical standards since the nurse is exercising undue influence on the client's choice. Therefore, if the nurse gives this response, a review of standards is needed. To give informed consent, the client must have all the information and understand it, and all of the client's questions should be answered. The other statements would indicate that the nurse understands this principle.

When a nurse attempts to make sure the health care provider obtained informed consent for a thyroidectomy, the nurse realizes the client doesn't fully understand the surgery. The nurse approaches the health care provider, who curtly says, "I've told this client all about it. Just get the consent." The nurse should: a) tell the health care provider the nurse cannot obtain informed consent at this point. b) tell the health care provider: "You didn't give the client enough information." c) explain the procedure more fully to the client and obtain the client's signature. d) ask the charge nurse to talk with the health care provider.

a) tell the health care provider the nurse cannot obtain informed consent at this point. - The nurse has evaluated the client's knowledge concerning the surgery and determined that the client doesn't have enough information to give informed consent. Even though the health care provider (HCP) wants to move ahead, the nurse should advocate for the client by asserting that the client isn't ready for the surgery. Stating that the HCP did not provide enough information is unlikely to gain the provider's cooperation and may be untrue: the HCP may have provided comprehensive information, but the client did not comprehend it all and requires further education. The nurse should not ask the charge nurse to talk with the HCP unless the HCP refuses to accept the nurse's professional opinion. Explaining surgery for the purpose of obtaining consent is beyond the nurse's scope of practice.

Several nurses from the medical unit access the electronic medical record of a well-known public official who was admitted to the emergency department. How should the nurse manager respond to the nurses regarding this situation? a) "It is understandable that you would be interested in the official's medical status." b) "Accessing the official's medical record is a breach of confidentiality." c) "You must not share the information you learn with others outside this unit." d) "We must maintain the official's confidentiality by denying that the official is a client here."

b) "Accessing the official's medical record is a breach of confidentiality." - The only people entitled to access the medical record are those who require access for care delivery. The other answers condone the medical unit nurses' breach of confidentiality and do not do anything to stop it from occurring. Clients identities are sometimes protected using pseudonyms or denial, but this is not routine or done simply because the client is well-known.

The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the best action by the nurse? a) Call the physician to request oral antibiotics. b) Flush the lock with heparin solution. c) Administer the prescribed antibiotics as prescribed. d) Insert a new IV medication lock and remove the old one.

d) Insert a new IV medication lock and remove the old one. - The nurse is to flush the medication IV lock every 8 to 12 hours, or depending on the facility policy. When flushing the IV lock, the nurse verifies the patency of the lock by aspirating blood return and the lock should flush without resistance. If the nurse is unable to flush without resistance, if there is leaking from the site during flushing, or if patency cannot be verified, the nurse should remove the IV lock and insert a new IV lock. If the nurse has resistance with flushing with saline, flushing with heparin would not be an appropriate option. The nurse should not administer the antibiotic if the IV lock is resistant during flushing. Calling the physician to change the order is not appropriate.

Two days after surgery to amputate the left lower leg, a client states that they have pain in the missing extremity. There is an existing prescription for PRN pain medication. Which action by the nurse is most appropriate? a) Administer medication for the reported discomfort. b) Contact the health care provider. c) Request a consult with a psychologist. d) Do nothing because it isn't possible to have pain in a missing limb.

a) Administer medication for the reported discomfort. - The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. Prescribed medication is one option for treating phantom pain. Since there is already a prescription for pain medication, the nurse doesn't need to contact the health care provider at this time. Consultation with the psychologist isn't indicated.

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action? a) Check health record for provider's order. b) Gather equipment and supplies. c) Assess urine characteristics. d) Explain the procedure to the client.

a) Check health record for provider's order. - The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after the order is confirmed.

A nurse administers digoxin 0.125 mg to a client at 1400 instead of the prescribed dose of digoxin 0.25 mg. Which statement should the nurse record in the medical record? a) Digoxin 0.125 mg given at 1400 instead of prescribed dose of 0.25 mg. b) Nurse accidentally gave digoxin 0.125 mg to the client at 1400. c) At 1400, wrong dose of digoxin given due to heavy workload. d) Digoxin 0.25 mg administered at 1400, physician notified.

a) Digoxin 0.125 mg given at 1400 instead of prescribed dose of 0.25 mg. - The nurse should not include judgment statements, opinion, assumptions, or conclusions about what happened. The nurse should simply state the occurrence. The other options present judgment, blame, and conclusion.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP? a) Initiating intravenous therapy b) Securing the client on a papoose board c) Soothing the client during the procedure d) Gathering equipment needed for intravenous therapy

a) Initiating intravenous therapy - When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of that condition, and the potential for harm. Initiating intravenous therapy is reserved for the RN due to the potential for harm and the scope of the UAP. The UAP can assist the nurse by obtaining equipment, securing the client, and soothing the client.

A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next? a) Look at the woman's hospital identification badge. b) Determine which hospital unit the woman works on. c) Inform the woman she cannot transport the baby. d) Ask if the client actually sent the woman.

a) Look at the woman's hospital identification badge. - Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. The nurse should review these policies and know the protocols for the facility in which the nurse will be working.

The nurse is administering vancomycin I.V. to a client. The pharmacy sent the correct dose, but it was to be administered 1 hour ago. What should the nurse do? Select all that apply. a) Notify the pharmacy of the late medication so they can change the time of the next dose. b) Complete any variance reports. c) Call the healthcare provider. d) Run the infusion as directed, and document the time it was started. e) Tell the nurse in the "hand-off" report that the medication and any associated labs need to be staggered.

a) Notify the pharmacy of the late medication so they can change the time of the next dose. b) Complete any variance reports. d) Run the infusion as directed, and document the time it was started. e) Tell the nurse in the "hand-off" report that the medication and any associated labs need to be staggered. - The nurse should start the dose when available, noting the time the medication was started; also the pharmacy should be notified so they can schedule the next dose accordingly; pass on the information about the late medication in the hand-off report; and complete any variance reports. The nurse does not need to call the healthcare provider because the medication will still be given, only at a later time and the labs will have adjusted times so that the physician will still get the needed labs that reflect the medication was given.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step? a) Read the consent form to the client and ask if there are any questions. b) Contact the client's nearest relative to obtain consent. c) Make sure the client's family is present when the consent form is signed. d) Document on the consent form that the client is unable to sign the consent because of being legally blind.

a) Read the consent form to the client and ask if there are any questions. - The nurse should read the consent form to the client and make sure that the client understands all the information. The healthcare provider should answer any questions the client has before the consent form is signed. The client's family doesn't need to be present, and there is no need to contact the client's closest relative. A client who is legally blind may sign the consent form.

A client newly diagnosed with congestive heart failure has a prescription for digoxin. The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care? a) The nurse withholds the medication and notifies the health care practitioner. b) The nurse administers the medication and reassesses the client after 30 minutes. c) The nurse withholds the medication, retakes the heart rate, and gives the medication at a later time. d) The nurse administers the medication after reviewing the client's serum potassium level.

a) The nurse withholds the medication and notifies the health care practitioner. - Nurses are responsible for following the standards of care for their particular work area. A reasonably prudent nurse would withhold the medication and notify the health care practitioner. All other options put the client's safety at risk and would not be done by a reasonably prudent nurse.

An informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems? a) Use of strong passwords b) Thorough knowledge of interoperability c) Intuitive system design d) Testing

a) Use of strong passwords - Nurses are responsible for minimizing the risk of harm to clients and providers through both system effectiveness and individual performance. Ensuring secure and appropriate access to clinical systems starts with good management of passwords, including the use of strong passwords. Interoperability and intuitive design are not associated components to ensure secure data. Testing is an important component in the system development lifecycle (SDLC).

A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? a) Verify consent. b) Document the start of surgery. c) Acquire ordered blood products. d) Count sponges and syringes.

a) Verify consent. - Surgery cannot be performed without consent. Documentation of the start of surgery can only happen once the surgery has started. Blood products must be administered within an allotted time frame and therefore should not be acquired unless needed. The sponge and syringe count is a safety issue that should be completed before surgery and while the wound is being sutured, but if the client has not consented, the surgery should not take place.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. b) urgent. c) required. d) elective.

a) emergency. - Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. Urgent surgery means that the client requires prompt attention within 24 to 30 hours. Required surgery means that the client needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Which nursing intervention demonstrates congruence in a therapeutic nurse-client relationship? a) getting an appointment with the client at the time previously agreed upon b) discussing the client's request for additional privileges with the treatment team c) sharing examples of stress management techniques d) implementing restatement as a therapeutic communication method

a) getting an appointment with the client at the time previously agreed upon - Congruence occurs when words and actions match. The nurse demonstrates this by fulfilling the promise made to the client. While the remaining options are appropriate behaviors that positively affect the nurse-client relationship, they do not demonstrate congruence.

A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN? a) 8-year-old child admitted that morning with suspected meningitis b) 9-year-old child receiving subcutaneous insulin for diabetes mellitus c) 10-year-old child who had a tonsillectomy that morning d) 9-year-old child with Legg-Calve'-Perthes disease

b) 9-year-old child receiving subcutaneous insulin for diabetes mellitus - The unit manager should assign the LPN/VN to the child with diabetes mellitus. Because the client is receiving subcutaneous insulin rather than IV insulin, the diabetes is likely stable. Meningitis is an acute condition with the potential to progress into respiratory depression and seizures; this child will require frequent nursing assessments. The child who had a tonsillectomy remains at risk for hemorrhage during the first 24 hours following surgery. Legg-Calve'-Perthes disease is associated with impaired circulation to the femoral capital epiphysis; the child with this condition requires aggressive monitoring.

The nurse observes a nursing assistant leave the room of client diagnosed with Clostridium difficile infection without washing hands. Which is the priority action by the nurse? a) Report the nursing assistant to the nurse manager. b) Have the nursing assistant wash hands with soap and water. c) Provide written documentation about the incident. d) Teach the nursing assistant about the chain of infection.

b) Have the nursing assistant wash hands with soap and water. - Although all actions listed are appropriate, the priority nursing action is to ensure that the nursing assistant washes their hands with soap and water. Allowing nursing assistants to continue with their job without washing their hands could lead to the nursing assistant infecting other clients with whom they come in contact. The potential for health care-associated acquisition is increased because the spore is relatively resistant to disinfectants and can be spread via the hands of healthcare providers.

A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply. a) Initiate an IV with dextrose. b) Have two nurses check the blood type and identity. c) Warm the blood to room temperature. d) Initiate an IV with normal saline. e) Take baseline vital signs.

b) Have two nurses check the blood type and identity. d) Initiate an IV with normal saline. e) Take baseline vital signs. - Prior to administering blood, the unit must be checked by two registered nurses. Baseline vital signs are obtained before the transfusion is started so any changes would be identified. Blood is always transfused with normal saline as other IV fluids are incompatible with blood. Warming to room temperature is not necessary.

Which teaching statement best exemplifies cultural competence in relation to time for the American culture? a) It is a sign of respect to be late for your health care appointments. b) It is important to be on time for your health care appointment. c) It is important to be future-oriented when considering your appointment time. d) It is important to arrive within 20 minutes of your scheduled appointment time.

b) It is important to be on time for your health care appointment. - In the United States, being on time and completing a job promptly are the expectation. This expectation is not the same in all cultures. It should be included when explaining cultural practice that timeliness is important. Being late for an appointment is considered disrespectful in the American culture.

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action? a) Discard the remaining drug. b) Place the date on the vial and retain for future use. c) Draw up the remaining medication to give at the next time of administration. d) Send the vial with the remaining drug back to the pharmacy

b) Place the date on the vial and retain for future use. - The nurse will place the date on the vial and retain it for future use since the vial is indicated for multiple uses. Other actions are incorrect.

A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? a) Make sure the UAP has practiced sterile technique on at least one other occasion. b) Reassign the UAP to a client requiring basic tasks that the UAP has mastered. c) Supervise the UAP during the treatments involving sterile technique. d) Provide the UAP with a list of resources to guide the implementation of care.

b) Reassign the UAP to a client requiring basic tasks that the UAP has mastered. - The nurse is accountable for the delegation of tasks to UAPs. The nurse delegates tasks to UAPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UAPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UAP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UAP has the knowledge and skill to provide the care or carry out the task.

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority? a) Extinguish the fire. b) Rescue the client. c) Raise an alarm. d) Confine the fire.

b) Rescue the client. - The first priority in case of fire is to rescue the client. As per the RACE principle of fire management, the rescue of the client is the first step, followed by raising an alarm, confining the fire, and finally, extinguishing the fire.

The pediatric nurse is preparing to administer ibuprofen to an 8-month-old infant. The infant's weight is listed in the computer as 15 kg (33 lb) and the medication is prescribed to be given 10 mg/kg. The nurse notices that the dose of 150 mg seems high for an infant. The nurse clarifies the prescription with the healthcare provider, who states that it is the correct dose. What should the nurse do? a) Administer the medication as prescribed because the healthcare provider said it is correct. b) Verify child's weight is accurate and, if it is correct, give the medication. c) Notify the healthcare provider's superior about the medication prescription. d) Document the healthcare provider's response on the medical record.

b) Verify child's weight is accurate and, if it is correct, give the medication. - Pediatric medication dosages are weight-based. In this scenario, the nurse has already verified the prescription is correct with the healthcare provider, and 10 mg/kg is a safe and standard dose for ibuprofen in pediatric clients. The nurse should verify the child's weight is accurate, because 15 kg (33 lb) for an 8-month-old infant is higher than the 99th percentile and, if it is accurate, the medication should be given as prescribed. The nurse should not just give the medication just because the healthcare provider said it is correct and should not notify a superior unless there is clearly an unsafe situation that cannot be resolved otherwise. The nurse should document the interaction but the priority is verifying the weight and accuracy of the prescription.

Socialization into the nursing profession may have the most significant effect on: a) roles. b) values. c) documentation. d) planning.

b) values. - Socialization into a culture refers not only to the adoption of practices, such as documentation and planning, and ways of relating to one another (roles) but to the very beliefs that one holds to be most important (values). Because values guide one's practices and roles, the most significant effect of socialization into nursing would be its effect on values.

A nurse is preparing to give a client an initial dose of a penicillin preparation. What should the first action be for the nurse? a) Ask the health care provider to order a skin test to assess for hypersensitivity to penicillin. b) Ask the client if the client wears a MedicAlert bracelet. c) Ask the client if there is a history allergy to a penicillin. d) Ask the client if there is a history of anaphylaxis.

c) Ask the client if there is a history allergy to a penicillin. - Before giving the initial dose of any penicillin preparation, ask the client if he or she has ever taken penicillin and, if so, whether an allergic reaction occurred. If the client is believed to be hypersensitive and the penicillin is considered essential, a skin test can help assess the degree of hypersensitivity; the provider can use the results of the test to determine whether and how to administer a penicillin to the client. Although penicillin is a common source of drug-induced anaphylaxis, not all anaphylaxis is caused by drugs.

The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action? a) Ask the nursing supervisor to validate the frequency as every 8 hours and update the electronic medical record (EMR). b) Input the prescription into the electronic medical record (EMR) to reflect that the drug is given every 8 hours, after verifying with the pharmacy. c) Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription. d) Ask another nurse to validate the frequency as every 8 hours, update the electronic medical record (EMR), flagging the prescription for the health care provider to review and cosign the prescription within 24 hours.

c) Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription. - The nurse should always have the health care provider clarify the prescription. The nurse cannot assume that a medication is to be given at certain times, nor should another nurse verify the frequency or clarify the prescription. The nurse should remain on the phone with the provider and read back the entire prescription for verification. Documentation should reflect that it is a phone prescription. Usually the phone prescription has to be reviewed and cosigned by the provider within 24 hours.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take? a) Strike through the entry ensuring the original entry is still visible. b) Rewrite the entry on the correct health record indicating who made the error. c) Contact the previous nurse requesting that the nurse correct the error. d) Report to the nurse manager that the nurse needs guidance on documentation.

c) Contact the previous nurse requesting that the nurse correct the error. - The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.

A charge nurse asks a group of staff nurses to cover part of the next shift because a nurse called off. A staff nurse states, "40 hours a week of nursing is all I can manage. I won't volunteer for overtime." The charge nurse tells the unit's nurse manager, "You should adjust her schedule to make her wish she'd volunteered." How should the nurse manager respond? a) Ignore the comment because the charge nurse made the statement under stress. b) Report the charge nurse to the nursing administration. c) Counsel the charge nurse about her comment. d) Tell the staff nurse what the charge nurse said about her.

c) Counsel the charge nurse about her comment. - It would be discriminatory and punitive for the nurse manager to alter the staff nurse's schedule. The remark by the charge nurse is inappropriate and unprofessional, and the charge nurse should receive counseling. The nurse manager could choose to ignore the comment, but any leader who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the charge nurse to the nursing administration should be avoided. Institutional documentation should exist for such matters. It is inappropriate for the nurse manager to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

A 73-year-old man has been the primary caregiver for his wife, who has multiple sclerosis (MS). After 30 years with the disease she died and he has become increasingly withdrawn and refuses to leave the house. Which nursing diagnosis is most appropriate? a) Low self-esteem related to feeling unloved now that his spouse has passed away b) Disturbed body image related to death of spouse and loss of the role of caregiver c) Disturbed personal identity related to the unresolved crisis of his wife's death d) Risk for altered self-esteem related to the recent death of his spouse

c) Disturbed personal identity related to the unresolved crisis of his wife's death - The client is experiencing disturbed personal identity as he is no longer a spouse or a caregiver. This is related to the recent death of his chronically ill spouse. Without her to care for he is unable to define who he is or what his role is without her. He does not have low self-esteem or disturbed body image.

A nurse is admitting a 7-year-old child to the pediatric unit of the hospital. While the nurse is showing the child and parents the room and explaining where things are, the child becomes upset and frightened. What is the best action by the nurse? a) Keep on showing and explaining to the parents and do not include the child. b) Tell the child that there is nothing to be afraid of and that nobody will hurt the child during hospitalization. c) Go slowly with the acquaintance process. d) Ask the parents to leave the room while explaining procedures to the child.

c) Go slowly with the acquaintance process. - The child who reacts with fear to well-meaning advances and who clings to the caregiver is telling the nurse to go slowly with the acquaintance process. The child who knows that the caregiver may stay is more quickly put at ease. To provide security for the child and to provide family-centered care, it is the responsibility of the nurse to form good partnerships with families. Asking the family to leave the room in this situation would only frighten the child more. The nurse should never provide false reassurance. Telling the child there is nothing to be afraid of or nothing will hurt him or her are promises the nurse cannot make to the child.

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating? a) Altruism b) Social justice c) Integrity d) Autonomy

c) Integrity - The principle of integrity is based on the honesty of a nurse according to professional standards. In this instance, the nurse reported the occurrence of the missed medication to the charge nurse. The definition of altruism is concern for others; it can best be explained by a nurse concerned about how a client will care for self after discharge. Social justice is a concept of fair and just relations between the individual and society and is related to wealth and distribution of goods in a society. Autonomy is the right to self-determination or acting independently and making decisions.

To obtain information about the chief complaint and medical history of an older client, the nurse asks the client about any medication history. Why is obtaining a medication history important? a) It may indicate the client's general health. b) It may reflect the client's childhood and family illnesses. c) It may indicate multiple medications taken by the client. d) It may indicate drugs that should not be prescribed to the client.

c) It may indicate multiple medications taken by the client. - The nurse should obtain information about a client's medication history because the older client, in particular, may be taking multiple medications that may affect their renal function. The medication history in general indicates the probable risk factors of renal or urologic disorders. The medication history of an older client is not used to obtain information about the client's general health, childhood and family illnesses, or drugs that are contraindicated for use by the client.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent? a) Ask the nursing supervisor to contact the hospital lawyer. b) Keep the client in the emergency department until the family is contacted. c) Take the client to the operating room for surgery without informed consent. d) Contact the hospital chaplain to sign the consent on the client's behalf.

c) Take the client to the operating room for surgery without informed consent. - All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed. The nurse should take the client to the operating room.

A nurse would perform handwashing instead of using an alcohol-based product for which situation? a) Before putting on sterile gloves for inserting a urinary catheter b) After taking a client's vital signs c) When hands are visibly soiled from client care d) During client care when moving from a contaminated body site to a clean one

c) When hands are visibly soiled from client care - Handwashing would be done when the hands become visibly dirty or contaminated with biologic material from client care. Otherwise, an alcohol-based product could be used, for example, before putting on gloves for inserting a urinary catheter, after taking a client's temperature or blood pressure, or during client care when moving from a contaminated body site to clean body site.

A nurse manager reviews an employee's contribution to the nursing division annually. This process is: a) interpreting quality indicators. b) employee's job satisfaction survey. c) performance appraisal. d) reward and development survey.

c) performance appraisal. - Performance appraisal is typically conducted annually. Each organization determines a reward structure to define and to acknowledge success. Interpreting quality indicators pertains to evaluation of general client care, not of an individual nurse. An employee's job satisfaction survey is a tool that allows the employee to give feedback on the employee's satisfaction with work, not a review of the employee's contribution conducted by the nurse manager.

The client is diagnosed with fibroid tumors and the surgeon states the uterus must come out. The nurse understands that the clients signature may be obtained on a consent, but obtaining informed consent for the surgery is the responsibility of whom? a) supervisor b) manager c) surgeon d) OR technician

c) surgeon - Informed consent is a legal procedure to ensure that the patient knows the benefits and costs of treatment. To provide informed consent for care, the patient must be given adequate information upon which to base decisions and actively participate in the decision-making process by the surgeon. It is not the supervisor, manager, or OR technician's responsibility to make sure the informed consent is signed, any one of these choices and the nurse can sign that the patient's signature is valid.

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process? a) Nurse b) Physician c) Physical therapist d) Patient

d) Patient - Although the nurse, physician, and physical therapist play important roles in the rehabilitation process, the patient is a key member of the rehabilitation team, the focus of the team's efforts, and the one who determines the final outcomes of the process.

The scrub nurse is responsible for: a) Calling the "time-out" to verify the surgical site and procedure b) Monitoring the administration of the anesthesia c) Monitoring the operating-room personnel for breaks in sterile technique d) Preparing the sterile instruments for the surgical procedure

d) Preparing the sterile instruments for the surgical procedure - The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.

A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response? a) Administer the medications. b) Hold the medications for Nurse A. c) Ask another staff nurse to give the medications. d) State, "I cannot give medications for other nurses."

d) State, "I cannot give medications for other nurses." - Nurses must never administer medications prepared by another nurse. Nurse B will professionally reply, "I cannot give medications for you." Nurse B should not hold the medications or ask another nurse to give the medications.

A nurse is discussing a surgical procedure with a client who needs to sign his informed consent. Which of these tasks is part of the nursing role? a) explaining to the client about potential risks of having the surgery b) describing how the client will benefit from the surgical procedure c) determining for the client what other treatment options exist d) witnessing the client signature with their consent for surgery

d) witnessing the client signature with their consent for surgery - The nursing role with informed consent is to witness the client signature on the form. The procedural physician is responsible for explaining the procedure, any alternative treatment, and the risks and benefits of having the surgery. The nurse may clarify information, but if in-depth explanation is needed, the procedural physician should be notified.