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
... [Show More] way to take care of this without having surgery?" The nurse has a duty to first:
1) Reassure the client that the surgery is the best treatment option
2) Tell the client if they don't want the surgery, they don't have to have it
3) Notify the surgeon that the client has additional questions about alternatives to surgery
4) Call the surgeon and cancel the surgery until the consent form is signed
3
Rationale:
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 is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?
1) Clinical specialty certification by an accredited organization
2) Complete and accurate documentation of assessments and interventions
3) Above-average performance reviews prepared by nurse manager
4) Sworn statement that health care provider orders were followed
2
Rationale:
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.
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 of these statements best illustrate the shared governance model?
1) Staff groups are appointed to discuss nursing practice and client education issues
2) Non-nurse managers supervise nursing staff in groups of units
3) Nursing departments share responsibility for client outcomes
4) An appointed board oversees any administrative decisions
3
Rationale:
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 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.)
1) The UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday
2) The UAP applies moisture barrier cream to the client's excoriated perianal area
3) The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall
4) The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue
5) The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor
3, 4, 5
Rationale:
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.
An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs) and is unable to drive.
Reorder the steps in the case management process by dragging and dropping the options below.
1) Evaluation of progress towards client's goals
2) Referral to personal care attendant and transportation services
3) Assessment of biophysical and sociocultural considerations
4) Identification of nursing diagnoses
5) Reassessment of health status and ADL ability
3, 4, 2, 5, 1
Rationale:
Case management is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs.
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?
1) The nurse is not required to report the mistake because the client was not harmed
2) The nurse is not responsible for the mistake because they have not been provided current education by their employer
3) The nurse will immediately be suspended and their license will be revoked
4) The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting
4
Rationale:
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.
A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects appropriate assertive communication?
1) "Would you please clarify what you have written so I am sure I am reading it correctly?"
2) "Please print in the future so I do not have to spend extra time attempting to read your writing."
3) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
4) "I cannot give this medication as it is written. I have no idea of what you mean."
1
Rationale:
Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.
All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first?
1) 62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8
2) 79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10
3) 70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery
4) 67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the dressing
1
Rationale:
A surgical client using a narcotic PCA is at risk for respiratory depression, which is potentially life-threatening, and therefore the top priority. The other clients need assessment and attention, but the priority is given to the client with a respiratory rate of 8. Some bloody drainage on a dressing is expected after a drain is removed and of course the nurse would monitor this. Constipation is a side effect of narcotics but is not life-threatening. Pain control is also important but does not take priority over respiratory depression.
The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)?
1) Teach the initial ostomy care to a client and family members
2) Provide stoma care for a client with a well-functioning ostomy
3) Assess the function of a newly created ileostomy
4) Care for a recent complicated double barrel colostomy
2
Rationale:
The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN.
The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM?
1) All employees participate in systematically working toward common goals
2) It is a reactionary approach used to investigate the root cause of a problem
3) It is an incident management technique that focuses on employee retention
4) Top administrators are responsible for establishing plans for problem management
1
Rationale:
TQM uses a strategic and systematic approach for continual improvement of processes, products, services and the workplace culture. The focus is on improving customer satisfaction. TQM involves all employees, not just top administrators. It is a proactive, not reactive, approach to solving problems.
The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse checks and then confirms that the client is not progressing on any part of the mobility training program. What action is the nurse's priority?
1) Contact the family to discuss preoperative mobility problems
2) Discuss the problem with the client's surgeon
3) Instruct physical therapy to increase treatments to four times a day
4) Inform the case manager of the variance in the critical pathway
4
Rationale:
Variances in the critical pathway need to be reported to the case manager. Certain goals need to be met to move the client forward in recovery and transfer to an appropriate venue for continued rehabilitation. The RN cannot order physical therapy treatment. Previous mobility problems are not priority post-operatively. The surgeon needs to be informed about the client's lack of progress, but this is not the priority.
The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other staff and visitors. Which approach by the nurse manager is indicated in this situation?
1) Request an immediate private meeting with the health care provider and staff nurse
2) Notify the chief nursing officer about the breach of professional conduct
3) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."
4) Stay neutral and allow the staff nurse to handle this situation independently
1
Rationale:
Assertive communication respects the needs of all parties to express themselves, but not at the expense of being in front of non-involved staff, visitors or clients. The nurse manager first needs to protect clients and other staff from this display of negative behavior and come to the assistance of the nurse employee. Privacy is a priority, as well as limiting the communication to only those involved.
A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medications." The nurse should respond with an understanding of which statement?
1) A referral is needed to the psychiatrist who should provide the client with answers to the request
2) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
3) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication's uses and side effects
4) The client has a right to know about the use and side effects of the prescribed medications
4
Rationale:
Clients have a right to informed consent, which includes detailed information about medications, treatments and diagnostic studies. The other options are incorrect approaches.
A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse?
1) Check with the nurse and the client often during the shift
2) Provide an immediate one-on-one, personal in-service about the drain
3) Assign the graduated staff nurse to be transferred to another floor for the shift
4) Change the assignment; reassign the client with the lumbar drain to a different nurse
4
Rationale:
One of the first principles of safe assignments is to match skills with the task. New nurses should not be assigned tasks for which they are not competent. The assignment needs to be changed. The other options simply help support the nurse but may be dangerous for the client. And, of course, the new nurse will need training about caring for a client with a lumbar drain.
The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority).
1) Blood and sputum cultures
2) Oxygen 2 liters nasal cannula
3) Fingerstick before each meal and at bedtime
4) Ceftriaxone (Rocephin) 1 gram every 12 hours IVPB
5) IV normal saline at 100 mL/hr
2, 1, 5, 4, 3
Rationale:
For establishing priorities, first look at the ABCs. Oxygen administration is the first priority (and the client's oxygen saturation is probably low given the patient has pneumonia). The next priority would be to have the lab come and draw blood for the cultures; this must be done prior to starting the antibiotics. Then an IV must be started (the antibiotic is ordered IV). Even though the patient is diabetic and it is dinner time, a finger stick is the last thing on the list to complete.
A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate?
1) Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care
2) Report to the nurse manager about the witnessed suspicious activity
3) Request to see identification and an explanation as to why the woman is viewing client charts
4) Immediately call security for this breach in client confidentiality
3
Rationale:
Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation.
A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse?
1) Report of unstable angina with continuous telemetry monitoring
2) Tracheostomy of 24 hours with the client showing some respiratory distress
3) Pacemaker insertion on the day shift
4) Dopamine IV drip with vital signs monitored every five minutes
3
Rationale:
The nurse from the float pool should be assigned to care for the most stable client, which is the client who had the pacemaker inserted on the day shift. The other clients are unstable and have potentially life-threatening conditions. In most critical care units, the nurse can titrate dopamine upward or downward; this requires the expertise of the nurse who normally works on this unit. Although tracheostomies are not limited to critical care units, a nurse unexperienced in critical care should not be assigned to the client with a newly created tracheostomy.
A registered nurse (RN) is working on the medical/surgical unit of a large medical center and needs to contact the health care provider regarding a change in a client's status.
List the order the nurse should present the following information by dragging and dropping the options below.
1) "Okay, Dr. White, I will write the order for oxycodone and acetaminophen (Percocet) 2.5 mg/325 mg - 1 or 2 tablets by mouth every 6 hours as needed for pain."
2) "Mr. Richmond reports increased pain in his knee. His heart rate is now 112 beats per minute, up from 80 beats a minute; his respiratory rate is 20; and he is afebrile. The ibuprofen 800 mg every 12 hours by mouth is not controlling his pain."
3) "Hello Dr. White, this is Pat Davis, an RN at the University Hospital on the third floor med-surg unit."
4) "I am calling about Mr. Stanley Richmond. He was admitted last night."
5) "I would like to recommend a change in pain medication. He has no known allergies to medications."
3, 4, 2, 5, 1
Rationale:
Using the acronym "I-SBAR-R" is an effective, structured, and easy method to use when communicating with other health care providers. QSEN has recommended this to be used as the standard. "I-SBAR-R" stands for: I = introduction, S = situation, B = background, A = assessment, R = recommendation, R = read back.
Correct!
The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most relevant as the nurse begins employment?
1) "Which physicians will I be more closely collaborating with?"
2) "Which groups are at the greatest risk for problems?"
3) "Which clients should I see as I begin my day?"
4) "Which nursing assistants can I refer clients to?"
2
Rationale:
Public health nursing is focused on improving the health status of the entire community. Although all the options are good to know, it is most important that the RN understands which groups in the community have the greatest health needs. Public health nurses collaborate with physicians, as well as with other health care providers, to assess and prioritize major health problems in the community. They also assist individuals and families to take action to improve their health status. Nursing assistants provide care for individual clients and families, but this question is more appropriate for a visiting or home health nurse.
A Bosnian Muslim woman who does not speak English seeks care at a community clinic. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice?
1) A female neighbor of the client who is also from Bosnia
2) A female interpreter who does not know the client
3) The client's adult daughter
4) A Bosnian male, who is a certified medical interpreter
2
Rationale:
When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter is needed. But, it may be inappropriate to have a male interpreter for a female client because the client may not be as forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client. The best response is to have a female interpreter who does not know the client.
The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time?
1) State strongly: "Stop. Tell me why there's no urine in the tubing."
2) Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter."
3) In a speaking tone of voice, explain: "The tubing is probably in the vagina."
4) Ask the student in a calm voice: "Did you do something wrong?"
2
When no urine appears after inserting a catheter into a female client, the catheter may be in the vagina. This catheter can be left in place and used as a landmark indicating where not to insert the new, sterile catheter. The best approach is for the nurse is to calmly remind the student about this technique and offer assistance. The other options are unprofessional and/or they may upset the client and the student.
The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What action should the nurse take next?
1) Ask another staff nurse to discuss the same concerns with the hospitalist
2) Request a consult with the in-house pharmacist
3) Page the attending physician to express the same concerns
4) Administer the medication as ordered
3
Rationale:
The scenario is an example of the "two-challenge rule." It is the nurse's responsibility to assertively voice concerns at least two times to ensure that it has been heard. If the outcome is still not acceptable, the nurse needs to take a stronger course of action by either contacting a supervisor or the attending physician to express the same concerns. The nurse must be an advocate for the client.
A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.)
1) Reconciliation of medications
2) Poor communication among providers
3) Client health status
4) Family preferences
5) Excellent primary care
2, 3, 4
Rationale:
Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care. [Show Less]