The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which
... [Show More] of these statements best illustrate the shared governance model?
A. Staff groups are appointed to discuss nursing practice and client education issues
B. Non-nurse managers supervise nursing staff in groups of units
C. Nursing departments share responsibility for client outcomes
D. An appointed board oversees any administrative decisions
C. Nursing departments share responsibility for client outcomes
Shared governance or self-governance is a method of organizational design. It promotes empowerment of nurses to give them responsibility for client care issues and outcomes with other divisions in the agency.
The triage nurse identifies that a 16-year-old client is legally married and has signed the consent form for treatment. What would be an appropriate action by the nurse?
A. Refer the teenager to a community pediatric hospital emergency department
B. Proceed with the triage process in the same manner as any adult client
C. Ask the teenager to wait until a parent or legal guardian can be contacted
D. Withhold treatment until telephone consent can be obtained from their partner
B. Proceed with the triage process in the same manner as any adult client
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years of age.
The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.)
A. the UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday
B. The UAP applies moisture barrier cream to the client's excoriated perianal area
C. The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall
D. The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue
E. The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor
C. The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall
D. The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue
E. The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor
The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee replacement surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail polish.
A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager?
A. Schedule a staff conference, without the nurse present, to collect information
B. Consult with human resources about the issue and needed actions
C. Confront the nurse about the suspicions in a private meeting
D. Counsel the employee to resign to avoid investigation and rumors
B. Consult with human resources about the issue and needed actions
The nurse manager needs to consult with human resources to determine the proper procedures for documenting and reporting the nurse's behavior. The nurse manager could also consult the EAP if one is available. If the staff nurse is also suspected of diversion, and a written policy exists, the nurse manager would follow these procedures. Attempts should be made to help the nurse with SUD by providing counseling and treatment for this disease.
A client who is unconscious is brought to the emergency department by an ambulance. What document should the nurse give priority to when preparing the care for this client?
A. A notarized original of the advance directive brought in by the partner
B. Orders written by the health care provider in the emergency department
C. The national statement of client rights and the client self-determination act
D. The clinical pathway protocol of the agency and the emergency department
A. A notarized original of the advance directive brought in by the partner
This document specifies the client's wishes of what actions are to be taken when the client becomes unable to make health care decisions. The advance directive often includes a living will and the power of attorney to whom will make the decisions for the client. The next document that would take precedent are the orders written by the heath care provider. The clinical pathways are used to evaluate the client's progress during therapy.
The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online?
A. There won't be any consequences because the information was posted on a website for nursing professionals
B. The nurse could be reprimanded for not clearing the information first with hospital administration
C. There won't be any consequences because the client's real name was not used
D. The nurse could be fired for breach of confidentiality
D. The nurse could be fired for breach of confidentiality
Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy.
A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first?
A. Tension pneumothorax with slight tracheal deviation to the right
B. Viral pneumonia with atelectasis
C. Spontaneous pneumothorax with a respiratory rate of 38
D. Acute asthma with episodes of bronchospasm
A. Tension pneumothorax with slight tracheal deviation to the right
Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side and cyanosis with a high risk of cardiac tamponade and cardiac arrest.
A client asks the nurse for information about a living will. Which statement made by the client dem onstrates an understanding of a living will? (Select all that apply.)
A. "It lists all my assets and how they should be divided among my family after I die."
B. "I should sit down and discuss my wishes for end-of-life care with my loved ones."
C. A living will must be renewed by a designated family member each time I am hospitalized."
D. "A living will is a legal document that becomes a permanent part of my health care record."
E. "My wishes for end-of-life treatment are stated in writing."
F. "I will need to identify someone to be my health care proxy."
A. "It lists all my assets and how they should be divided among my family after I die."
B. "I should sit down and discuss my wishes for end-of-life care with my loved ones."
D. "A living will is a legal document that becomes a permanent part of my health care record."
E. "My wishes for end-of-life treatment are stated in writing."
F. "I will need to identify someone to be my health care proxy."
An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf. A living will does not expire; it remains in effect unless it is changed. A living will does not include information regarding assets or a person's estate.
A client's uncle calls for an update on the condition of his nephew. What should the nurse do first before providing the information to the caller?
A. Call the physician to verify the client's condition before you speak to the family member
B. Ask the family member that is currently at the client's bedside if it is okay to release the information to the client's uncle
C. Consult with the client and obtain permission to update the client's uncle of his condition
D. Refuse to release any information to the family member and remind them they must be present to obtain an update
C. Consult with the client and obtain permission to update the client's uncle of his condition
You must have permission by the client to release information to the family member. If your client is unable to give permission and has a health care proxy, then information can only be given to the health care proxy and all family members can obtain updates from the proxy. Remember, it is difficult to know who is calling over the phone. Consult your organization's policy on condition requests over the phone.
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?
A. Clinical specialty certification by an accredited organization
B. Complete and accurate documentation of assessments and interventions
C. Above-average performance reviews prepared by nurse manager
D. Sworn statement that health care provider orders were followed
B. Complete and accurate documentation of assessments and interventions
The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.
A client is being prepped for a surgical procedure and the nurse is reviewing the informed consent with the client. The client asks, "Is there any other way to take care of this without having surgery?" The nurse has a duty to first:
A. Reassure the client that the surgery is the best treatment option
B. Tell the client if they don't want the surgery, they don't have to have it
C. Notify the surgeon that the client has additional questions about alternatives to surgery
D. Call the surgeon and cancel the surgery until the consent form is signed
C. Notify the surgeon that the client has additional questions about alternatives to surgery
The client has a right to an explanation of the treatment and its expected results, anticipated risks and benefits, possible alternative treatment options and all questions answered before a consent form is signed. Remember, the client is not asking you for your opinion. The client is asking about alternative treatments for the condition. Notify the appropriate health care provider if the client needs additional information that you cannot answer. Once the client has all the necessary information then they can decide not to sign the informed content and cancel the surgery.
A nurse has unintentionally given an incorrect dose of medication to their client. No harm was done to the client. What is the next action, if any, required by the nurse?
A. The nurse is not required to report the mistake because the client was not harmed
B. The nurse is not responsible for the mistake because they have not been provided current education by their employer
C. The nurse will immediately be suspended and their license will be revoked
D. The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting
D. The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting
Although the client was not harmed as a result of the mistake, the incident still needs to be reported. Nurses are responsible for their practice and for staying current and competent by becoming lifelong learners. In this case, neither an immediate suspension nor revoking a license are warranted. [Show Less]