Module 5 Exam
Questions
1. 1.ID: 327498249
A client with leukemia is being considered for a bone marrow transplant. The healthcare team is
discussing
... [Show More] the 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.
TestTaking Strategy: Use the process of elimination and think about 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 the principles of healthcare ethics if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 314). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 327496879Which action by the nurse represents the ethical principle of beneficence?
A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer.
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.
TestTaking 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 if
you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 327498211
The nursing instructor asks a student to name an example of false imprisonment. Which of the
following situations 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 permissionRationale: 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.
TestTaking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship
of the subject and the words in the correct option. If you had difficulty with this question, review the
concept of false imprisonment.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 175, 176). St. Louis: Mosby.
Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p. 424).
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 327497519
A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the
floor. The nurse should 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 physician 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 nursing assistant to assist in getting the client
into bed. The nurse should then contact the physician and file an incident report.
TestTaking 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 incidentreports if you had difficulty with this question.
References: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patient–centered
collaborative care (6th ed., p. 180). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 327496885
Which of the following actions exemplifies the use of evidencebased 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 physician
D. Taking a rectal temperature from a client for whom bleeding precautions have
been instituted
Rationale: Evidencebased 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 evidencebased practice,
because it prevents the entrance of harmful bacteria into the wound. The remaining options do not
reflect evidencebased 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 temperaturetaking is avoided in the client for whom bleeding precautions
have been instituted.
TestTaking Strategy: Read each option carefully, focusing on the subject, evidencebased practice.
Recall the definition of evidencebased practice and note the words “sterile gloves” in the correct
option. Review the situations that reflect evidencebased practice if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 5460). St. Louis:
Mosby.Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 327497573
The registered nurse has accepted a new position as case manager in a hospital. Which of the
following 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 costeffective 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 costeffective 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, selfcare 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.
TestTaking 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.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 21). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 327497511
The nurse manager of a quality improvement program asks a nurse in the neurological unit to
conduct a retrospective audit. Which of the following actions 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 shift
B. 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.
TestTaking 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.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 327497529
A 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 healthcare 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.
TestTaking Strategy: Use the process of elimination and 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 if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 1387). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
9. 9.ID: 327497555A 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. The
nurse should:
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
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.
TestTaking Strategy: Use the process of elimination and 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 if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p. 1387). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 327497559
A nurse preparing a client to go to the radiology department for a chest xray 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 xray 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 xray [Show Less]