MODULE 5 Questions
1. 1.ID: 9477027534
A client with leukemia is being considered for a bone marrow transplant. The healthcare team is
discussing the
... [Show More] risks and benefits of this treatment and other possible treatments with the goal of
inflicting the least possible harm on the client. Which principle of healthcare ethics is the team
practicing?
A. Justice
B. Fidelity
C. Autonomy
D. Nonmaleficence Correct
Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics,
ethical practice involves not only the will to do good but also the equal commitment to do no harm.
Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do
the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of
resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients,
families, and other healthcare professionals. Autonomy refers to a person’s independence and
represents an agreement to respect another’s right to determine his or her course of action.
Test-Taking Strategy: Focus on the subject - the ethical principle being utilized. Recall the definition
of each item in the options. Note the relationship of the words “least possible harm” in the question
and the definition of nonmaleficence. Review: principles of healthcare ethics.
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2. 2.ID: 9477024200
Which action by the nurse represents the ethical principle of beneficence?
A. The nurse upholds a client’s decision to refuse chemotherapy for lung
cancer. Incorrect
B. The nurse follows a plan of care designed to relieve pain in a client with cancer.
C. The nurse administers an immunization to a child even though it may cause
discomfort. Correct
D. The nurse provides equal amounts of care to all assigned clients on the basis of
illness acuity.
Rationale: Beneficence is taking action to help others. Although administration of a child’s
immunization might cause discomfort, the benefits of protection from disease outweigh the
temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare
professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that
you are agreeing to respect that person’s right to determine his or her course of action. Justice refers
to fairness and equity, including fair allocation of resources, such as nursing care for all clients.
Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking
action to help others will direct you to the correct option. Review: the principles of healthcare ethics .
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3. 3.ID: 9477029451The nursing instructor asks a student to name an example of false imprisonment. Which situation
reflects a violation of this client right?
A. Performing a procedure without consent
B. Telling the client that he or she may not leave the hospital Correct
C. Threatening to give a client a medication against his or her will
D. Observing the provision of care to the client without the client’s permission
Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment.
Performing a procedure without consent is an example of battery. Threatening to give a client a
medication against his or her will is assault. Invasion of privacy takes place with unreasonable
intrusion into an individual’s private affairs. Observing the provision of care to a client without the
client’s permission is an example of invasion of privacy.
Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship
of the subject and the words in the correct option. Review: the concept of false imprisonment.
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4. 4.ID: 9477017756
The nurse and an unlicensed assistive personnel (UAP)enter a client’s room to provide care and find
the client lying on the floor. Which action should the nurse take first?
A. Ask the nursing assistant to complete an incident report
B. Check the client’s level of consciousness and vital signs Correct
C. Ask the nursing assistant to assist in getting the client back to bed
D. Contact the unit secretary on the intercom and ask that the client’s health care
provider be called
Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should
check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained
in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to
move the client, the nurse should ask the UAP to assist in getting the client into bed. The nurse
should then contact the health care provider and file an incident report.
Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer
the question. The correct option is the only one that addresses assessment. Remember to always
assess the client first if a client sustains a fall. Review: client injuries and procedures for filing
incident reports .
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5. 5.ID: 9477020809
Which action exemplifies the use of evidence-based practice in the delivery of client care?
A. Donning sterile gloves to change an abdominal wound dressing Correct
B. Encouraging a client to take an herbal substance to treat his insomnia
C. Advising a client to agree to the treatment recommended by her health care
provider
D. Taking a rectal temperature from a client for whom bleeding precautions have
been institutedRationale: Evidence-based practice is an approach to client care in which the nurse integrates the
client’s preferences, clinical expertise, and the best research evidence to deliver quality care.
Donning sterile gloves to change an abdominal wound dressing reflects evidence-based practice,
because it prevents the entrance of harmful bacteria into the wound. The remaining options do not
reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is
nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to
the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions
have been instituted.
Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice.
Recall the definition of evidence-based practice and note the words “sterile gloves” in the correct
option. Review: the situations that reflect evidence-based practice .
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6. 6.ID: 9477020817
The registered nurse has accepted a new position as case manager in a hospital. Which
responsibilities are part of the nurse’s new role? Select all that apply.
A. Evaluating and updating the plan of care as needed Correct
B. Prescribing treatments specific to the client’s needs
C. Assessing the client’s needs for home supplies and equipment Correct
D. Coordinating consultations and referrals to facilitate discharge Correct
E. Establishing a safe and cost-effective plan of care with the client Correct
Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care
from the point of admission through, and after, discharge. Specific responsibilities of the case
manager include establishing a safe and cost-effective plan of care with the client, coordinating
consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or
clinical pathway as appropriate to guide care and evaluating and updating the plan of care as
needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s
diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment
such as oxygen or wound care supplies and exploring available resources to provide the client with
these supplies; providing resources that will assist the client in maintaining independence as much
as possible; and providing the client with information on discharge procedures and the plan of care.
The nurse does not prescribe treatments.
Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word
“prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review: the
responsibilities of the case manager if you have difficulty with this question.
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7. 7.ID: 9477028765
The nurse manager of a quality improvement program asks a nurse in the neurological unit to
conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of
audit?
A. Checking the documentation written by a new nursing graduate on her assigned
clients at the end of the shiftB. Checking the crash cart to ensure that all needed supplies are readily available
should an emergency arise
C. Reviewing neurological assessment checklists for all clients on the unit to ensure
that these assessments are being conducted as prescribed
D. Obtaining the assigned medical record from the hospital’s medical record room
to review documentation made during a client’s hospital stay Correct
Rationale: Quality improvement, also known as performance improvement, is focused on processes
or systems that significantly contribute to client safety and effective client care outcomes. Criteria are
used to assess outcomes of care and determine the need for changes improve the quality of care. In
a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge
for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the
nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are
providing care during the client’s stay. In this type of audit, a peer review approach in which
members of the nursing staff are involved in data collection may be implemented. Obtaining the a
client’s medical record from the medical record room for the purpose of reviewing documentation
made during the client’s hospital stay is an example of a retrospective audit. The incorrect options
are examples of concurrent audits.
Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word
“retrospective” in the question and the description in the correct option. Review: the procedures for
quality improvement and retrospective and concurrent audits if you have difficulty with this question.
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8. 8.ID: 9477022320
The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace.
What should the nurse do to safeguard the client’s necklace?
A. Ask the client whether the necklace is gold
B. Ask the client for permission to lock the necklace in the hospital safe Correct
C. Ask the client to remove the necklace and place it in the top drawer of the
bedside table
D. Ask the client to sign a release to free the hospital of responsibility if the
necklace is damaged or lost during the procedure
Rationale: When a client has valuables, the nurse should give them to a family member or secure
them for safekeeping. Most health care institutions require that a client sign a release form that frees
the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not
safeguard the client’s necklace. Valuables may be locked in a designated location such as the
hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the
client whether the necklace is gold is inappropriate and unrelated to the subject.
Test-Taking Strategy: Focus on the subject, safeguarding the client’s necklace. Focusing on the
subject and noting the word “lock” in the correct option will help you answer correctly. Review: the
procedures for safeguarding a client’s valuables .
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9. 9.ID: 9477017796The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary
lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which
action should the nurse take?
A. Tape the wedding band in place
B. Explain to the client why the wedding band must be removed Correct
C. Ask the client whether she would like to remove the wedding band or wear it to
surgery Incorrect
D. Ask the client to sign a release to free the hospital of responsibility if the wedding
band is lost during surgery
Rationale: In most situations a wedding band may be taped in place and worn during a surgical
procedure. However, if the possibility exists that the client will experience swelling of the hand or
fingers, the wedding band should be removed. On admission to a healthcare facility, the client is
asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After
mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in
swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask
the client to remove the wedding band and explain why.
Test-Taking Strategy: Focus on the data in the question. Eliminate the options that are comparable
or alike in that they indicate that the client may wear the wedding band during the surgical
procedure. Next, recall the complications associated with mastectomy, which will direct you to the
correct option. Review: preoperative procedures for a client’s valuables .
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10. 10.ID: 9477014230
The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client
is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern
about removing the medal. What is the most appropriate action for the nurse to take?
A. Asking the client to remove the medal until the x-ray has been completed
B. Assisting the client in pinning the medal and chain to the waistband of the client’s
pajama bottoms Correct
C. Asking the client to place the medal in the top drawer of the bedside stand just
before leaving for the radiology department
D. Telling the client that the medal and chain will be kept at the nurses’ station for
safekeeping while the client is undergoing the x-ray Incorrect
Rationale: A client undergoing a chest x-ray must remove all metal objects to help prevent artifacts
on the x-ray. If the client expresses concern about removing the medal, the nurse should help the
client pin the medal and chain to the hospital gown or in another area where it will not appear on the
x-ray image. The nurse should also alert staff in the radiology department that this has been done. If
the client is expressing concern about removing the medal, asking the client to remove it or leave it
with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the
likelihood that the medal and chain will be lost.
Test-Taking Strategy: Note that the client is expressing concern about removing the religious medal.
Eliminate the options that are comparable or alike in that they indicate that the client should removethe medal. Also note that the correct option is the only option that addresses the client’s concern.
Review: care of clients’ valuables
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11. 11.ID: 9477030405
A health care provider writes a medication prescription in a client’s record. While transcribing the
prescription, the nurse notes that the prescribed dose is three times higher than the recommended
dose. The nurse calls the health care provider, who states that this is the dose that the client takes at
home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse
to take?
A. Contacting the nursing supervisor Correct
B. Continuing to transcribe the prescription Incorrect
C. Asking the nurse assigned to care for the client to administer the medication
D. Verifying the prescribed dose with the client before administering the medication
Rationale: A nurse must follow a physician’s prescription unless he or she believes that the
prescription is in error or that it would harm the client. If a prescription is found to be incorrect or
harmful, further clarification from the health care provider is necessary. If the health care provider
confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact
the nursing supervisor. The nurse should not continue transcribing the prescription or ask another
nurse to implement the prescription. The nurse might ask the client about the medication and the
dose taken at home but would not administer the medication.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the
medication would be administered. Review: the nurse’s responsibilities in regard to a physician’s
prescriptions .
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12. 12.ID: 9477016885
The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal
chamber. After further assessment, the nurse suspects that the client’s lung has reexpanded and
notifies the health care provider. The health care provider verifies with the use of a chest x-ray that
the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action
should the nurse take first?
A. Call the nursing supervisor
B. Explain the procedure to the client, then remove the chest tube
C. Inform the health care provider that removal of a chest tube is not a nursing
procedure Correct
D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in
removing the chest tube
Rationale: Actual removal of a chest tube is the duty of a health care provider. Therefore the nurse
would first inform the health care provider that this is not a nursing procedure. If the health care
provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some
agency’s policies and procedures may permit an advanced practice nurse (a nurse with a master’s
degree in a specialized area of nursing) to remove a chest tube. However, there is no information inthe question to indicate that the nurse is an advanced practice nurse.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the
nurse would remove the chest tube. To select from the remaining options, note the strategic word
“first.” The nurse should discuss the prescription with the physician. Review: nursing responsibilities
with regard to removal of a chest tube .
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13. 13.ID: 9477025841
The nurse calls a health care provider to report that a client with congestive heart failure (CHF) is
exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because
of a situation in the emergency department, gives the nurse a telephone prescription for furosemide
(Lasix) but does not specify the route of administration. What is the appropriate action on the part of
the nurse?
A. Calling the health care provider who gave the telephone prescription to clarify the
prescription Correct
B. Calling the nursing supervisor for assistance in determining the route of
administration
C. Administering the medication intravenously, because this route is generally used
for clients with CHF
D. Administering the medication orally and clarifying the prescription once the
health care provider has finished caring for the client in the emergency department
Rationale: Telephone prescriptions involve a health care provider’s dictating a prescribed therapy
over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription
clearly and precisely to the physician. The nurse then writes the prescription on the physician’s
prescription sheet. Under no circumstances should the nurse try to interpret an unclear prescription
or administer a medication by a route that has not been expressly prescribed. The nurse must call
the health care provider who gave the telephone prescription and clarify the prescription.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the
nurse should administer the medication without clarifying the physician’s prescription. Review: the
procedures for accepting telephone prescriptions .
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14. 14.ID: 9477026697
A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment,
the health care provider is paged to report to the recovery room. The health care provider leaves the
client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the
intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation?
A. Calling the nursing supervisor to obtain permission to accept the verbal
prescription
B. Changing the solution and rate of the IV fluid per the physician’s verbal
prescription
C. Asking the health care provider to write the prescription in the client’s record
before leaving the nursing unit CorrectD. Telling the health care provider that the prescription will not be implemented until
it is documented in the client’s record
Rationale: The health care provider should write all prescriptions. Verbal prescriptions are not
recommended, because they increase the risk for error. If a verbal prescription is necessary, such as
during an emergency, it should be written and signed by the health care provider as soon as
possible, usually within 24 hours. The nurse must follow agency policies and procedures regarding
verbal prescriptions. The appropriate nursing action would be to ask the health care provider to write
the prescription in the client’s record before leaving the nursing unit. Changing the solution in
keeping with the verbal prescription and contacting the supervisor to obtain permission to accept the
verbal prescription each imply that the nurse accepts the verbal prescription. Telling the health care
provider that the prescription will not be implemented until it is documented in the client’s record
delays necessary treatment.
Test-Taking Strategy: and note the strategic word “appropriate.” Eliminate the options that are
comparable or alike in that they imply acceptance of the verbal prescription by the nurse. To select
from the remaining options, recall the guidelines and principles for implementing health care provider
prescriptions. This will direct you to the correct option. Review: nursing responsibilities related to
verbal prescriptions .
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15. 15.ID: 9477014249
A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical
procedure but was never told about the risks of the surgery. The nurse serves as the client’s
advocate by taking which action?
A. Reassuring the client that the risks are minimal
B. Calling the surgeon and asking that the risks be explained to the client Correct
C. Noting in the client’s record that the client was not told about the risks of the
surgery
D. Writing a note on the front of the client’s record so that the surgeon will see it
when the client arrives in the operating room [Show Less]