Post by Nursing Board 101 on Aug 18, 2010 13:19:04 GMT -5
1. If parents or legal guardians aren't available to give consent for treatment of a life-threatening situation in a minor child, which of the following statements is most accurate?
a.)Consent may be obtained from a neighbor or close friend of the family.
b.)Consent may not be needed in a life-threatening situation.
c.)Consent must be in the form of a signed document; therefore, parents or guardians must be contacted.
d.)Consent may be given by the family physician.
B. RATIONALE: In emergencies, including danger to life or possibility of permanent injury, consent may be implied, according to the law. Parents have full responsibility for the minor child and are required to give informed consent whenever possible. Verbal consent may be obtained.
2. You're admitting a 15-month-old boy who has bilateral otitis media and bacterial meningitis. Which room arrangements would be best for this client?
a.)In isolation off a side hallway
b.)A private room near the nurses' station
c.)A room with another child who also has meningitis
d.)A room with two toddlers who have croup
B. RATIONALE: With meningitis, the child should be isolated for the first day but be close to where he can be observed frequently. In isolation off a side hallway is too far away for frequent observation. Putting the client in a room with another child who has meningitis or with two toddlers who have croup present an infectious hazard to the other children.
3. Which of the following points should a team leader consider when delegating work to team members in order to conserve time?
a.)Assign unfinished work to other team members.
b.)Explain to each team member what needs to be done.
c.)Relinquish responsibility for the outcome of the work.
d.)Assign each team member the responsibility to obtain dietary trays.
B. RATIONALE: When all team members know what needs to be done, they can work together on the most efficient plan for accomplishing necessary tasks. Delegation can be flexible, ranging from telling a staff member exactly what needs to be done and how to do it to allowing team members some freedom to decide how best to carry out the tasks. Assigning unfinished work to other team members and assigning each team member the responsibility to obtain dietary trays don't allow for input from team members. It's the team leader's job to maintain responsibility for the outcome of a task.
4. The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless:
a.)the client is mentally ill.
b.)the client refuses to give informed consent.
c.)the client is in an emergency situation.
d.)the client asks the nurse to give substituted consent.
C. RATIONALE: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. Even though a client who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent.
5. The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as:
a.)a quality improvement issue.
b.)an ethical dilemma.
c.)an informed consent problem.
d.)a risk-management incident.
D. RATIONALE: The nurse should treat this episode as a risk-management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident.
6. The nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What's the appropriate action for the nurse to take?
a.)Speak to the manager and document in writing all concerns related to the assignment.
b.)Refuse the assignment.
c.)Ignore the assignment and leave the unit.
d.)Trade assignments with another nurse.
A. RATIONALE: When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice.
7. The nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells the nurse that standard precautions and gloves aren't necessary unless the client is known to have tested positive for the human immunodeficiency virus. What's the most appropriate action for the nurse to take?
a.)Ignore it because it isn't directly the nurse's problem
b.)Document the problem in writing for the manager.
c.)Talk to other staff members to ascertain their practices.
d.)Instruct the clients to remind this colleague to wear gloves.
B. RATIONALE: The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't meeting standards.
8. An adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for the client is also his friend. The nurse tells the client's parents about the diagnosis; after all, they know their son is the nurse's friend. Several weeks later, the nurse receives a letter from the client's attorney stating that the nurse has committed an intentional tort. Which intentional tort has this nurse committed?
a.)Fraud
b.)Defamation of character
c.)Assault and battery
d.)Breach of confidentiality
D. RATIONALE: A nurse shouldn't disclose confidential information about a client to a third party who has no legal right to know; doing so is a breach of confidentiality. Defamation of character is injuring someone's reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the client's will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment.
9. A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should:
a.)call the facility's attorney.
b.)inform the client's family.
c.)complete an incident report.
d.)do nothing because the client's condition is stable.
C. RATIONALE: The nurse should file an incident report. Incident reports highlight areas of potential liability. It's then the risk manager's responsibility to notify the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option.
10. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
a.)encourage the client to ask questions about personal sexuality.
b.)provide time for privacy.
c.)provide support for the spouse or significant other.
d.)suggest referral to a sex counselor or other appropriate professional.
D. RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.
11. The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation?
a.)The nurse may assign the two nonprofessionals to work independently with a client assignment.
b.)The nurse is responsible to supervise assistive personnel.
c.)Nonprofessionals aren't responsible for their own actions.
d.)Nonprofessionals don't require training before they work with clients.
B. RATIONALE: Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform.
12. Each state has guidelines that regulate the different levels of nursing & licensed practical or vocational nurse, registered nurse, or advanced practice nurse. Legal guidelines outlining the scope of practice for nurses are known as:
a.)consent to treatment.
b.)client's bill of rights.
c.)nurse practice acts.
d.)licensure requirements.
C. RATIONALE: Each state has a nurse practice act that defines the scope of nursing practice within the state. Consent to treatment refers to informed consent for a treatment or procedure. The client's bill of rights defines the rights of clients. Licensure requirements are constructed by the state board of nursing to set standards for receiving a nursing license.
13. A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to:
a.)detain him until he signs the paperwork.
b.)detain him until his physician arrives.
c.)call security for assistance.
d.)let him leave.
D. RATIONALE: The nurse is obligated to let him leave. Detaining him in any form is a violation of the patient's bill of rights.
14. A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasn't:
a.)properly educated this client about safety measures.
b.)restrained the client.
c.)documented that she left the client.
d.)arranged for continual care of the client.
D. RATIONALE: By leaving the client, the nurse is at fault for abandonment. The better course of action is to turn on the call bell or elicit help on the way to the client's room. Educating the client about safety measures doesn't alleviate the nurse from responsibility for ensuring the client's safety. The nurse can't restrain the client without a physician's order and restraints won't ensure the client's safety. Documenting that she left the client doesn't excuse the nurse from her responsibility for ensuring the client's safety.
15. When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be:
a.)allowing the family to see a newly admitted client.
b.)ambulating the client in the hallway.
c.)administering pain medication.
d.)placing wrist restraints on the client.
C. RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity is on the second layer. Safety is on the third layer. Love and belonging are on the fourth layer.
16. When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship:
a.)at discharge.
b.)during the first meeting.
c.)at the midpoint of the relationship.
d.)when the client demonstrates the ability to function independently.
B. RATIONALE: When initiating a therapeutic relationship with a client, preparation for termination of the relationship should begin during the first meeting. For example, the nurse should introduce herself to the client and tell him exactly when she'll be involved in his care. This sets the boundaries of the relationship. In the middle and at discharge of care, the relationship may be too involved to end abruptly without warning. The client's ability to function independently isn't the deciding factor in preparing the client for the termination of the therapeutic relationship.
17. To be effective, a clinical nurse-manager in a managed care environment must:
a.)expect all staff to accept change.
b.)go along with a proposed change.
c.)be a catalyst for change.
d.)document staff nurses' reactions to change.
C. RATIONALE: The clinical nurse-manager is responsible for making things happen, not just letting things happen. She must be more than a role model who goes along with change & she must also encourage change and support staff during change. Documentation of the nurses' reactions to change can be threatening and serves no purpose in helping change to occur.
18. In community-based nursing, primary responsibility for decisions related to health care belongs to the:
a.)nurse.
b.)client.
c.)health care team.
d.)physician.
B. RATIONALE: The client is primarily responsible for health care decisions in community-based nursing. The nurse assists with monitoring of health treatment and teaching and intervenes only as needed after assessing the client's ability to follow a regimen. The health care team collaborates on decisions related to treatment. The physician dictates medical orders related to treatment and medication.
19. A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who is most likely to be held liable?
a.)No one because it was an accident
b.)The hospital
c.)The nurse
d.)The nurse and the hospital
D. RATIONALE: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, both the nurse and the hospital are liable. Although the mistake wasn't intentional, standard procedure wasn't followed.
20. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
a.)change his own dressing.
b.)walk in the hallway.
c.)walk from his room to the end of the hall and back before discharge.
d.)eat a special diet.
C. RATIONALE: Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.
21. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client?
a.)Tell him that it's a legal question beyond the scope of nursing practice.
b.)Give him a copy of the client's bill of rights.
c.)Provide information on active euthanasia.
d.)Discuss documenting his wishes in an advance directive.
D. RATIONALE: Advance directives give a competent client control over his situation and a legal forum in which to express his wishes about his care. Discussion of advance directives isn't outside the scope of nursing practice. The client's bill of rights involves multiple client rights and doesn't provide detailed information about advance directives. Active euthanasia is illegal.
22. While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to:
a.)document findings thoroughly.
b.)question the client about the bruising.
c.)inform appropriate local authorities.
d.)tell the client's physician.
C. RATIONALE: This client may be experiencing elder abuse based on her history and symptoms. Authorities to be notified may include local social service or law enforcement agencies. The nurse should also document findings and include illustrations to support the assessment. The client with Alzheimer's disease may not be able to accurately inform the nurse about what happened. Reporting findings to the physician may not be sufficient for fulfilling the nurse's legal responsibility.
23. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource can best help the client adapt to the disease?
a.)The client's family
b.)Pastoral care
c.)Support group
.)Hospice care
C. RATIONALE: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease-related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life.
24. A client with brain cancer is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time?
a.)Approach the client's family about organ donation.
b.)Make the decision to withdraw life support.
c.)Sedate the client.
d.)Talk to the staff about their feelings.
A. RATIONALE: The most appropriate nursing intervention is to discuss organ donation with the family. The decision to withdraw life isn't within a nurse's scope of practice. Because the client is brain-dead, he doesn't need sedation. Although talking to the staff is a viable strategy for staff decompression, it isn't the first action to take.
25. A client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
a.)Social worker
b.)Registered dietitian
c.)Occupational therapist
d.)Enterostomal nurse therapist
D. RATIONALE: An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Social workers provide counseling and emotional support, but they can't provide preoperative and postoperative teaching. A registered dietitian can review any dietary changes and help the client with meal planning. The occupational therapist can assist a client with regaining independence with activities of daily living.
26. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which intervention should the nursing care plan include?
a.)Check on the client once per shift.
b.)Provide mouth and skin care only if the family requests it.
c.)Turn the client only if he's uncomfortable.
d.)Provide emotional support and pain relief.
D. RATIONALE: When advance directives state that a client doesn't want life-prolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers.
27. The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the registered nurse understands that the unlicensed assistant:
a.)interprets clinical data.
b.)collects clinical data.
c.)is trained in the nursing process.
d.)can function independently.
B. RATIONALE: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. The registered nurse has learned critical thinking skills and is able to interpret the clinical findings. Unlicensed assistants are trained to perform skills & they don't learn the nursing process. Unlicensed assistants don't function independently & they're assigned tasks by a registered nurse who retains overall responsibility for the client. Other nursing responsibilities when delegating tasks to unlicensed assistants include knowing the institutions policies regarding delegation, knowing the assistant's training, knowing the client's needs, receiving frequent updates from the assistant, asking specific questions, and making frequent rounds of clients.
28. A nurse on a medical-surgical floor is making assignments for an 8-hour shift. Which of the following considerations has the highest priority?
a.)Complexity of care required
b.)Age of the clients
c.)Skills of the assigned personnel
d.)The number of clients
C. RATIONALE: The nurse is legally responsible for assigning personnel according to skill level. All of the other factors are important but don't take priority.
29. The nurse is caring for a homeless client with active tuberculosis. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which intervention will best ensure that the client complies with treatment?
a.)Referring the client to a social worker for discharge planning
b.)Providing individualized client education
c.)Having the client attend a formal education session
d.)Attempting to contact a member of the client's family to provide assistance
A. RATIONALE: Referring the client to a health care professional with knowledge of community resources is the best intervention to ensure compliance in a homeless client. Educating the client about his condition may help, but basic needs for shelter, food, and clothing must be met first. Providing formal education and attempting to contact family members are inappropriate when seeking to help a homeless client.
30. The nurse is following a critical pathway to help a client who underwent hip replacement surgery meet specific objectives. What's a critical pathway?
a.)A nursing care plan that helps the nurse to decide which intervention to perform first
b.)A multidisciplinary care plan that helps the nurse to use a variety of critical interventions
c.)A standardized care plan that lists basic interventions for the nurse to use with every client
d.)A clinical management tool that organizes the major interventions for a multidisciplinary health care team
D. RATIONALE: Critical pathways are management tools developed for particular types of cases or conditions. They set forth expectations for interventions, outcomes, and client progression. Elements of the nursing care plan are commonly folded into the critical pathway. The descriptions of standardized and multidisciplinary plans of care don't adequately describe the critical pathway. Because the critical pathway is standardized and multidisciplinary, the nurse may need to develop a separate care plan to document nursing diagnoses for an individual client.
a.)Consent may be obtained from a neighbor or close friend of the family.
b.)Consent may not be needed in a life-threatening situation.
c.)Consent must be in the form of a signed document; therefore, parents or guardians must be contacted.
d.)Consent may be given by the family physician.
B. RATIONALE: In emergencies, including danger to life or possibility of permanent injury, consent may be implied, according to the law. Parents have full responsibility for the minor child and are required to give informed consent whenever possible. Verbal consent may be obtained.
2. You're admitting a 15-month-old boy who has bilateral otitis media and bacterial meningitis. Which room arrangements would be best for this client?
a.)In isolation off a side hallway
b.)A private room near the nurses' station
c.)A room with another child who also has meningitis
d.)A room with two toddlers who have croup
B. RATIONALE: With meningitis, the child should be isolated for the first day but be close to where he can be observed frequently. In isolation off a side hallway is too far away for frequent observation. Putting the client in a room with another child who has meningitis or with two toddlers who have croup present an infectious hazard to the other children.
3. Which of the following points should a team leader consider when delegating work to team members in order to conserve time?
a.)Assign unfinished work to other team members.
b.)Explain to each team member what needs to be done.
c.)Relinquish responsibility for the outcome of the work.
d.)Assign each team member the responsibility to obtain dietary trays.
B. RATIONALE: When all team members know what needs to be done, they can work together on the most efficient plan for accomplishing necessary tasks. Delegation can be flexible, ranging from telling a staff member exactly what needs to be done and how to do it to allowing team members some freedom to decide how best to carry out the tasks. Assigning unfinished work to other team members and assigning each team member the responsibility to obtain dietary trays don't allow for input from team members. It's the team leader's job to maintain responsibility for the outcome of a task.
4. The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless:
a.)the client is mentally ill.
b.)the client refuses to give informed consent.
c.)the client is in an emergency situation.
d.)the client asks the nurse to give substituted consent.
C. RATIONALE: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. Even though a client who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent.
5. The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as:
a.)a quality improvement issue.
b.)an ethical dilemma.
c.)an informed consent problem.
d.)a risk-management incident.
D. RATIONALE: The nurse should treat this episode as a risk-management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident.
6. The nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What's the appropriate action for the nurse to take?
a.)Speak to the manager and document in writing all concerns related to the assignment.
b.)Refuse the assignment.
c.)Ignore the assignment and leave the unit.
d.)Trade assignments with another nurse.
A. RATIONALE: When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice.
7. The nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells the nurse that standard precautions and gloves aren't necessary unless the client is known to have tested positive for the human immunodeficiency virus. What's the most appropriate action for the nurse to take?
a.)Ignore it because it isn't directly the nurse's problem
b.)Document the problem in writing for the manager.
c.)Talk to other staff members to ascertain their practices.
d.)Instruct the clients to remind this colleague to wear gloves.
B. RATIONALE: The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't meeting standards.
8. An adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for the client is also his friend. The nurse tells the client's parents about the diagnosis; after all, they know their son is the nurse's friend. Several weeks later, the nurse receives a letter from the client's attorney stating that the nurse has committed an intentional tort. Which intentional tort has this nurse committed?
a.)Fraud
b.)Defamation of character
c.)Assault and battery
d.)Breach of confidentiality
D. RATIONALE: A nurse shouldn't disclose confidential information about a client to a third party who has no legal right to know; doing so is a breach of confidentiality. Defamation of character is injuring someone's reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the client's will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment.
9. A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should:
a.)call the facility's attorney.
b.)inform the client's family.
c.)complete an incident report.
d.)do nothing because the client's condition is stable.
C. RATIONALE: The nurse should file an incident report. Incident reports highlight areas of potential liability. It's then the risk manager's responsibility to notify the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option.
10. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
a.)encourage the client to ask questions about personal sexuality.
b.)provide time for privacy.
c.)provide support for the spouse or significant other.
d.)suggest referral to a sex counselor or other appropriate professional.
D. RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.
11. The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the nurse. Which statement is valid in this situation?
a.)The nurse may assign the two nonprofessionals to work independently with a client assignment.
b.)The nurse is responsible to supervise assistive personnel.
c.)Nonprofessionals aren't responsible for their own actions.
d.)Nonprofessionals don't require training before they work with clients.
B. RATIONALE: Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform.
12. Each state has guidelines that regulate the different levels of nursing & licensed practical or vocational nurse, registered nurse, or advanced practice nurse. Legal guidelines outlining the scope of practice for nurses are known as:
a.)consent to treatment.
b.)client's bill of rights.
c.)nurse practice acts.
d.)licensure requirements.
C. RATIONALE: Each state has a nurse practice act that defines the scope of nursing practice within the state. Consent to treatment refers to informed consent for a treatment or procedure. The client's bill of rights defines the rights of clients. Licensure requirements are constructed by the state board of nursing to set standards for receiving a nursing license.
13. A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to:
a.)detain him until he signs the paperwork.
b.)detain him until his physician arrives.
c.)call security for assistance.
d.)let him leave.
D. RATIONALE: The nurse is obligated to let him leave. Detaining him in any form is a violation of the patient's bill of rights.
14. A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasn't:
a.)properly educated this client about safety measures.
b.)restrained the client.
c.)documented that she left the client.
d.)arranged for continual care of the client.
D. RATIONALE: By leaving the client, the nurse is at fault for abandonment. The better course of action is to turn on the call bell or elicit help on the way to the client's room. Educating the client about safety measures doesn't alleviate the nurse from responsibility for ensuring the client's safety. The nurse can't restrain the client without a physician's order and restraints won't ensure the client's safety. Documenting that she left the client doesn't excuse the nurse from her responsibility for ensuring the client's safety.
15. When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be:
a.)allowing the family to see a newly admitted client.
b.)ambulating the client in the hallway.
c.)administering pain medication.
d.)placing wrist restraints on the client.
C. RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity is on the second layer. Safety is on the third layer. Love and belonging are on the fourth layer.
16. When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship:
a.)at discharge.
b.)during the first meeting.
c.)at the midpoint of the relationship.
d.)when the client demonstrates the ability to function independently.
B. RATIONALE: When initiating a therapeutic relationship with a client, preparation for termination of the relationship should begin during the first meeting. For example, the nurse should introduce herself to the client and tell him exactly when she'll be involved in his care. This sets the boundaries of the relationship. In the middle and at discharge of care, the relationship may be too involved to end abruptly without warning. The client's ability to function independently isn't the deciding factor in preparing the client for the termination of the therapeutic relationship.
17. To be effective, a clinical nurse-manager in a managed care environment must:
a.)expect all staff to accept change.
b.)go along with a proposed change.
c.)be a catalyst for change.
d.)document staff nurses' reactions to change.
C. RATIONALE: The clinical nurse-manager is responsible for making things happen, not just letting things happen. She must be more than a role model who goes along with change & she must also encourage change and support staff during change. Documentation of the nurses' reactions to change can be threatening and serves no purpose in helping change to occur.
18. In community-based nursing, primary responsibility for decisions related to health care belongs to the:
a.)nurse.
b.)client.
c.)health care team.
d.)physician.
B. RATIONALE: The client is primarily responsible for health care decisions in community-based nursing. The nurse assists with monitoring of health treatment and teaching and intervenes only as needed after assessing the client's ability to follow a regimen. The health care team collaborates on decisions related to treatment. The physician dictates medical orders related to treatment and medication.
19. A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who is most likely to be held liable?
a.)No one because it was an accident
b.)The hospital
c.)The nurse
d.)The nurse and the hospital
D. RATIONALE: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, both the nurse and the hospital are liable. Although the mistake wasn't intentional, standard procedure wasn't followed.
20. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
a.)change his own dressing.
b.)walk in the hallway.
c.)walk from his room to the end of the hall and back before discharge.
d.)eat a special diet.
C. RATIONALE: Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.
21. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to prolong his life. He asks what he must do to make these wishes known and legally binding. How should the nurse respond to the client?
a.)Tell him that it's a legal question beyond the scope of nursing practice.
b.)Give him a copy of the client's bill of rights.
c.)Provide information on active euthanasia.
d.)Discuss documenting his wishes in an advance directive.
D. RATIONALE: Advance directives give a competent client control over his situation and a legal forum in which to express his wishes about his care. Discussion of advance directives isn't outside the scope of nursing practice. The client's bill of rights involves multiple client rights and doesn't provide detailed information about advance directives. Active euthanasia is illegal.
22. While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to:
a.)document findings thoroughly.
b.)question the client about the bruising.
c.)inform appropriate local authorities.
d.)tell the client's physician.
C. RATIONALE: This client may be experiencing elder abuse based on her history and symptoms. Authorities to be notified may include local social service or law enforcement agencies. The nurse should also document findings and include illustrations to support the assessment. The client with Alzheimer's disease may not be able to accurately inform the nurse about what happened. Reporting findings to the physician may not be sufficient for fulfilling the nurse's legal responsibility.
23. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource can best help the client adapt to the disease?
a.)The client's family
b.)Pastoral care
c.)Support group
.)Hospice care
C. RATIONALE: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences helps the client understand disease-related problems and gives him a forum in which he can vent his feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, can't share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life.
24. A client with brain cancer is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time?
a.)Approach the client's family about organ donation.
b.)Make the decision to withdraw life support.
c.)Sedate the client.
d.)Talk to the staff about their feelings.
A. RATIONALE: The most appropriate nursing intervention is to discuss organ donation with the family. The decision to withdraw life isn't within a nurse's scope of practice. Because the client is brain-dead, he doesn't need sedation. Although talking to the staff is a viable strategy for staff decompression, it isn't the first action to take.
25. A client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
a.)Social worker
b.)Registered dietitian
c.)Occupational therapist
d.)Enterostomal nurse therapist
D. RATIONALE: An enterostomal nurse therapist is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. Social workers provide counseling and emotional support, but they can't provide preoperative and postoperative teaching. A registered dietitian can review any dietary changes and help the client with meal planning. The occupational therapist can assist a client with regaining independence with activities of daily living.
26. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's advance directive, which intervention should the nursing care plan include?
a.)Check on the client once per shift.
b.)Provide mouth and skin care only if the family requests it.
c.)Turn the client only if he's uncomfortable.
d.)Provide emotional support and pain relief.
D. RATIONALE: When advance directives state that a client doesn't want life-prolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers.
27. The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the registered nurse understands that the unlicensed assistant:
a.)interprets clinical data.
b.)collects clinical data.
c.)is trained in the nursing process.
d.)can function independently.
B. RATIONALE: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. The registered nurse has learned critical thinking skills and is able to interpret the clinical findings. Unlicensed assistants are trained to perform skills & they don't learn the nursing process. Unlicensed assistants don't function independently & they're assigned tasks by a registered nurse who retains overall responsibility for the client. Other nursing responsibilities when delegating tasks to unlicensed assistants include knowing the institutions policies regarding delegation, knowing the assistant's training, knowing the client's needs, receiving frequent updates from the assistant, asking specific questions, and making frequent rounds of clients.
28. A nurse on a medical-surgical floor is making assignments for an 8-hour shift. Which of the following considerations has the highest priority?
a.)Complexity of care required
b.)Age of the clients
c.)Skills of the assigned personnel
d.)The number of clients
C. RATIONALE: The nurse is legally responsible for assigning personnel according to skill level. All of the other factors are important but don't take priority.
29. The nurse is caring for a homeless client with active tuberculosis. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which intervention will best ensure that the client complies with treatment?
a.)Referring the client to a social worker for discharge planning
b.)Providing individualized client education
c.)Having the client attend a formal education session
d.)Attempting to contact a member of the client's family to provide assistance
A. RATIONALE: Referring the client to a health care professional with knowledge of community resources is the best intervention to ensure compliance in a homeless client. Educating the client about his condition may help, but basic needs for shelter, food, and clothing must be met first. Providing formal education and attempting to contact family members are inappropriate when seeking to help a homeless client.
30. The nurse is following a critical pathway to help a client who underwent hip replacement surgery meet specific objectives. What's a critical pathway?
a.)A nursing care plan that helps the nurse to decide which intervention to perform first
b.)A multidisciplinary care plan that helps the nurse to use a variety of critical interventions
c.)A standardized care plan that lists basic interventions for the nurse to use with every client
d.)A clinical management tool that organizes the major interventions for a multidisciplinary health care team
D. RATIONALE: Critical pathways are management tools developed for particular types of cases or conditions. They set forth expectations for interventions, outcomes, and client progression. Elements of the nursing care plan are commonly folded into the critical pathway. The descriptions of standardized and multidisciplinary plans of care don't adequately describe the critical pathway. Because the critical pathway is standardized and multidisciplinary, the nurse may need to develop a separate care plan to document nursing diagnoses for an individual client.