An alert, competent client admitted following a motor vehicle collision refuses emergency surgical intervention due to personal religious convictions. What is the nurse's priority action?
Correct Answer: B
Rationale: Competent adult clients have the legal right to refuse any medical treatment under the principle of autonomy. The nurse must verify comprehension of risks, document thoroughly, and notify the provider.
Should the nurse discard the first urine or last urine for a 24 hour urine?
What is informatics?
•Defined as the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making
how many stages of sleep are there
4
what does clubbing on the fingers indicate
chronic hypoxia
A nurse is caring for a client who is admitted to an oncology unit and is experiencing severe anxiety regarding an upcoming, painful bone marrow biopsy. The nurse promises the client, "I will stay right by your side and hold your hand throughout the entire procedure tomorrow morning." The next day, a staffing shortage occurs, and the charge nurse assigns the nurse to care for a newly admitted, unstable client in another room at the exact same time as the biopsy. Which of the following ethical principles is most at risk of being compromised if the nurse abandons the promise to the oncology client?
A. Autonomy
B. Veracity
C. Fidelity
D. Beneficence
Rationale (Fidelity - Correct): Fidelity refers to the duty to keep promises, fulfill commitments, and be faithful to the agreements made with clients. By promising to stay with the client and then facing a situation where that commitment might be broken, the nurse is dealing with a classic breach or challenge to the principle of fidelity.
what kind of prevention is cardiac rehab after an MI
tertiary
A nurse is documenting client care in the electronic health record (EHR). Which entry reflects objective, legally defensible nursing documentation?
Correct Answer: C
Rationale: Legal documentation must be objective, factual, and free of judgmental or subjective bias. Option C records direct quotes, objective findings, and specific nursing actions.
What are 2 major signs of OSA
snoring and fatigue
what is orthopnea
SOB while laying flat or almost flat
A nurse is providing care for a client who is admitted to an inpatient psychiatric unit. During a one-on-one interaction, the client tells the nurse, "I am so glad I'm here, because as soon as I get out, I am going to buy a gun and shoot my former business partner for ruining my life." Which of the following actions should the nurse take first?
A. Maintain client confidentiality by documenting the statement in the medical record without further action.
B. Notify the client's provider and the treatment team immediately regarding the threat.
C. Contact the former business partner directly to warn them of the potential danger.
D. Inform the client that their statement must be reported because it violates unit rules.
Rationale (Correct): Under the legal and ethical precedent established by the Tarasoff ruling (duty to warn/protect), healthcare professionals have a legal obligation to breach client confidentiality when a client makes a specific, credible threat of violence against an identifiable third party. However, the nurse's first internal chain-of-command action is to notify the provider and the interprofessional care team so safety interventions and proper legal steps (such as notifying law enforcement and the intended victim) can be initiated safely and systematically.
Rationale (Incorrect - A): Maintaining confidentiality does not apply when there is a clear, imminent threat of physical harm to an identifiable person. Doing nothing violates the duty to protect.
Rationale (Incorrect - C): While warning the victim is a necessary step of the duty to warn, a bedside nurse does not independently contact outside civilians. The nurse must first report the threat up the chain to the provider, charge nurse, and risk management/security so the facility can follow proper legal protocols.
Rationale (Incorrect - D): Lecturing the client or framing it simply as a "unit rule violation" trivializes a severe safety and legal threat, and it is not the most constructive initial clinical action.
what kind of prevention is a flu vaccine
primary
Which of the following is a primary focus of the U.S. health care delivery system according to the Affordable Care Act (ACA)?
1. Provide health insurance exclusively to employed individuals.
2. Focus on increasing hospital revenue through premium hikes.
3. Expand the Medicaid program to adults with incomes below 138% of the poverty level.
4. Eliminate the need for health insurance by providing universal coverage.
3.
A major goal of the ACA is to expand Medicaid coverage to adults whose incomes are below 138% of the federal poverty level.
Which nursing intervention is most effective for promoting restorative sleep and comfort in a hospitalized client recovering from surgery?
Correct Answer: B
Rationale: Clustering care protects sleep architecture by minimizing disruptions during normal circadian sleep cycles, promoting healing and comfort.
how would you explain to do pursed lip breathing and why would we do it
inhale through your nose and out through your mouth. they would do it when they are SOB
A nurse working in a busy emergency department notices that a colleague is visibly exhausted, overwhelmed, and falling behind on charting due to an influx of high-acuity clients. Although the nurse has completed their own assigned documentation and is ready to leave for a scheduled vacation, they quietly log back into the electronic health system to take over the care coordination and discharge planning for two of the colleague's stable clients. Which of the following professional values is the nurse demonstrating?
A. Altruism
B. Beneficence
C. Human dignity
D. Social justice
Rationale (Altruism - Correct): Altruism is defined as a concern for the welfare and well-being of others. In this scenario, the nurse displays unselfish concern by sacrificing their own personal time and delaying vacation to protect the well-being of both a stressed coworker and the clients under their care.
what dose a purple or black stoma mean?
decrease circulation, NOT normal
Why is safe nurse staffing considered a key advocacy issue in health policy?
1. Because increasing staffing always leads to lower costs for hospitals.
2. Because inadequate staffing affects client outcomes and nurse satisfaction.
3. Because it eliminates the need for evidence-based practice.
4. Because it is mandated solely by The Joint Commission.
2.
Safe nurse staffing ensures quality care, improves client outcomes, and enhances nurse satisfaction, making it a focal point for advocacy.
What are 3 major side effects of sleep deprivation
Mood swings, depression, migraines
what are the 2 main ways to prevent atelectasis
incentive spirometry and deep breathing
A nurse is caring for a client who has a terminal diagnosis and is experiencing severe, intractable pain. The client requests that the provider increase their opioid pain medication dose, acknowledging that the higher dose may risk respiratory depression but stating they want relief. The nurse advocates for the client's prescription change to ensure comfort. Which of the following ethical principles is the nurse demonstrating?
A. Autonomy
B. Beneficence
C. Justice
D. Altruism
Correct Answer: B. Beneficence
Rationale (Beneficence - Correct): Beneficence is a core biomedical ethical principle that refers to the duty to act to promote the well-being and best interests of others—in this specific clinical context, taking positive steps to relieve the client's suffering and ensure comfort.
where is an ileostomy located
where is a colostomy located
Right lower abdomen
Left lower abdomen
a fixed dollar amount you pay for a specific healthcare service
What does the pineal glad do?
•manufactures melatonin (a natural substance that helps the body prepare for sleep)
What are 3 s/s of oxygen toxicity
headache, muscle twitching, dizziness , confusion, changes in vision, seizures, nausea, fatigue