1
The LPN (LVN) assigns part of the care for her patients to a nursing assistant. The LPN is legally required to perform which of the following for the residents assigned to the assistant?
a. Toilet the residents every 2 hours and as needed.
b. Feed breakfast to one of the residents who needs assistance.
c. Give medications to the residents at the prescribed times.
d. Transport the residents to the physical therapy department
c. Give medications to the residents at the prescribed times.
Toileting, feeding, and transporting residents or patients are tasks that can be legally assigned to a nurse’s aide. Administering medications is a nursing act that can be performed only by a licensed nurse or by a student nurse under the supervision of a licensed nurse.
An elderly, slightly confused patient sustains an injury from a heating pad that was wrongly applied by the nurse. The nurse should:
a. pretend to be unaware of the injury to the patient.
b. report the incident to the risk management team via an incident report.
c. document in the patient’s medical record that an incident report was filled out.
d. not document anything about the injury in the patient’s medical record.
B
When an incident occurs that has potential for a future lawsuit, the risk management team should be aware of it as soon as possible. An incident report should be filled out, and the patient medical record should be documented to describe the injury. No mention of the incident report is usually made in the patient medical record. Honesty and a forthright explanation to the patient reduce the risk of lawsuits.
he nurse clarifies that nursing orders are also called:
a. goals.
b. qualifiers.
c. interventions.
d. measurement criteria.
C
Nursing orders are also called nursing interventions and follow the same requirements when placed in a nursing care plan.
The nurse caring for a terminally ill patient with renal failure would question an order for pain control that prescribed:
a. methadone.
b. oxycodone.
c. meperidine.
d. morphine.
C
Patients in renal failure cannot adequately clear meperidine (Demerol) from their system and will become oversedated.
A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurological impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)
a. Assist with range of motion exercises every 4 hours and as needed.
b. Instruct patient to call for assistance when needing to get out of bed.
c. Apply wrist and ankle restraints to promote safety and prevent falls.
d. Teach about exercises that will strengthen muscles while lying in bed.
e. Ambulate with physical therapy assistance at least three times a day.
ABDE
The nurse selects appropriate nursing interventions to alleviate the problems and assist the patient in achieving the expected outcomes. Consider all possible interventions for relief of the problems and then select those most likely to be effective.
A person who has been brought to the emergency room after being struck by a car insists on leaving, although the doctor has advised him to be hospitalized overnight. The nurse caring for this patient should:
a. have him sign a Leave Against Medical Advice (AMA) form.
b. tell him that he cannot leave until the doctor releases him.
c. immediately begin the process of involuntary committal.
d. contact the person’s health care proxy to assist in the decision-making process.
A person has the right to refuse medical care, and agencies use the Leave AMA to document the medical advice given and the patient’s informed choice to leave against that advice.
Ethics and law are different from each other in that ethics:
a. bear a penalty if violated.
b. are voluntary.
c. rarely change.
d. can always direct all decisions.
B
Ethics are voluntary and are based on values. Ethics may change as parameters of health care change. There is no penalty for violation.
The team leader who is reviewing the list of the assigned patients would give priority to the patient who:
a. has a scheduled medication due.
b. requires dressing changes three times a day.
c. is experiencing acute chest pain.
d. is confused and disoriented.
C
Unstable patients take precedence over stable patients. Scheduled medications and treatments must be done before tasks that are ordered “three times a day.”
Professional accountability includes: (Select all that apply.)
a. understanding theory.
b. adhering to the dress code of the facility.
c. asking for assistance when unsure of a procedure or primary care provider order.
d. participating in continuing education classes.
e. meeting the health care needs of the patient.
f. reporting patient health status changes to all family members
ACDE
Professional accountability is a nurse’s responsibility to meet the health care needs of the patient in a safe and caring application of nursing skills and understanding of human needs.
Appropriate nursing roles in the initial assessment would include: (Select all that apply.)
a. LPN obtains the vital signs of a new patient.
b. RN performs a complete physical assessment.
c. LPN organizes data into a database.
d. RN reviews the patient’s medical record for past medical/surgical history.
e. LVN contributes ongoing assessments.
ABDE
The LPN/LVN, under the NFLPN standard, contributes assessments; the RN performs the physical assessment and medical records review and organizes the database.
A patient has advance directives spelled out in a durable power of attorney, with the appointment of his daughter as his health care agent. The daughter will be responsible for:
a. paying all the medical bills associated with the father’s illness.
b. making all informed consent decisions for her father.
c. making all choices about her father’s health care if the father is unable.
d. paying only for those health care decisions based on the advance directives.
C
A health care agent makes decisions for the patient only when a patient is unable, according to the wishes made known by the patient in advance directives. A health care agent is not responsible for financial decisions or payments.
A written statement expressing the wishes of a patient regarding future consent for or refusal of treatment in case the patient is incapable of participating in decision making is an example of:
a. a privileged relationship.
b. a health care agent.
c. an advance directive.
d. witnessed will.
C
An advance directive makes the patient’s wishes known regarding medical decisions and consent in the event that he or she is unable to participate in decision making.
A nurse is caring for a patient who is being discharged. However, the patient’s blood pressure is elevated. The primary care provider enters orders for discharge. Which is the best response of the nurse acting as an advocate for the patient?
a. The nurse states to the patient, “Your primary care provider has discharged you. When you get home call his office for an appointment to have your blood pressure rechecked.”
b. The nurse states to the primary care provider, “I refuse to discharge the patient because his blood pressure is too high.”
c. The nurse states to her co-worker, “The patient’s blood pressure is too high to be discharged. I think I will tell the patient that it is too high, and that it puts him at risk for another stroke?”
d. The nurse states to the primary care provider, “The patient’s diastolic blood pressure is up to 112 mm Hg this morning, should he still be discharged?”
D
Role as patient advocate is one of your most important nursing roles. There are times when you must speak up when you disagree with the decisions or actions of others. Speaking up can be intimidating, especially to someone with more experience than you.
Tools you can employ:
The Two Challenge Rule: Voicing your concern at least twice to promote acknowledgment by the receiver. The first challenge is usually in the form of a question (“Doctor, the patient is having blood pressure problems, should she still be discharged?”). The second challenge should provide support for the concern and may be presented by the person making the initial challenge or by another team member (“The patient has had a drop in blood pressure of 20 mm Hg, and her heart rate has increased by 30 beats/min. I am concerned that she is too unstable to be discharged home.”). The two-challenge rule ensures that the concern has been heard, understood, and acknowledged.
A nurse arrives at the scene of a motor vehicle accident. A person in the vehicle mumbles incoherently when asked his name. Which actions are not covered by the Good Samaritan Law? (Select all that apply.)
a. Using two magazines and a bandana to splint a broken arm
b. Applying a tourniquet to a lacerated leg while awaiting emergency personnel
c. Pulling the individual from the surface of the highway
d. Initiating an emergency tracheotomy when the individual goes into respiratory arrest
e. Compressing a bleeding wound with a soiled shir
D
The Good Samaritan Law covers care given in an emergency, but only within the scope of one’s practice, and care that does not cause harm resulting from negligence.
A nursing diagnosis identifies: (Select all that apply.)
a. patient’s response to illness.
b. related signs and symptoms.
c. underlying medical diagnosis.
d. causative factors.
e. potential risk for health problems.
ABDE
Defining characteristics of nursing diagnosis includes the patient’s response to illness and the causative factors. Signs and symptoms must also be identified for a nurse to select an appropriate nursing diagnosis. Medical diagnoses label an illness; nursing diagnoses are independent of medical diagnoses.
A nurse remarks to several people that “Dr. X must be getting senile because she makes so many mistakes.” If that remark results in some of Dr. X’s patients changing to another doctor, Dr. X would have grounds to sue the nurse for:
a. slander.
b. libel.
c. invasion of privacy.
d. negligence.
A
A person who makes untrue, malicious, or harmful remarks that damage a person’s reputation and cause injury (loss of business) is guilty of defamation and slander. Libel is defamation that is written.
The nursing diagnoses that has the highest priority is:
a. Mobility, impaired physical, related to muscular weakness as evidenced by the inability to walk without assistance.
b. Communication, impaired verbal, related to neuromuscular weakness as evidenced by facial weakness and inability to speak.
c. Imbalanced nutrition: less than body requirements, related to difficulty swallowing and inadequate food intake as evidenced by weight loss of 10 pounds.
d. Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.
D
Choking and aspiration are life-threatening events and take priority over problems such as weakness, inability to speak, or weight loss.
he patient in hospice care says to the hospice nurse, “I want you to read my obituary that I just wrote.” The nurse assesses that this patient is in the Satir Blevins (2008) stage of:
a. practice.
b. chaos.
c. integration.
d. acceptance.
A
According to the Satir Blevins theory of loss (2008), this patient is in the phase of practice. The patient is practicing with the writing of the obituary the fact that life is coming to an end.
The Ethics Committee of a facility has the responsibility to: (Select all that apply.)
a. develop policies.
b. address issues in their facility.
c. modify the established codes of ethics as suits the situation.
d. create a master plan for decision making to be followed in ethical dilemmas.
e. help to find a better understanding of ethical dilemmas from different standpoints.
ABE
An Ethics Committee of an institution has representatives from various fields to formulate, address, and help clarify ethical problems that present themselves in their facility.
The statements that are correctly stated as expected outcomes are: (Select all that apply.)
a. patient will be able to void in the bathroom independently.
b. patient will be able to ambulate using a walker independently within 3 days.
c. the nurse will assist the patient to the bathroom three times a day.
d. patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours.
e. the family will bring food from home to improve patient appetite.
BD
Expected outcomes need to have a time frame and be measurable. Ambulating with a walker within 3 days and performing ROM independently for 4 hours are both measurable outcomes with clear time frames. The outcome of voiding independently does not have a time frame. Assisting the patient to the bathroom is a nursing intervention.
A postoperative patient in the intensive care unit (ICU) is so confused and agitated that staff have not been able to safely care for him. He has pulled out his central line once, and he slides to the bottom of the bed, where he attempts to climb out, pulling and disrupting the various tubes and monitors. The nurse’s best course of action is to:
a. place him in a protective vest device.
b. use a sheet to tie him in a chair at the nurses’ station.
c. request that the doctor write an order for a protective device and/or medication.
d. call a family member to stay with the patient.
C
A protective device may not be used (except in an emergency) without a doctor’s order, and it is used only when other less restrictive means do not provide safety for the patient.
The nurse takes into consideration that the difference between a sign and a symptom is that a sign is:
a. subjective data.
b. unreliable because it depends on translation.
c. can be verified by examination.
d. something a patient reports that is verified by a relative.
C
Signs are objective data that can be confirmed by examination, assessment, or observation. Signs are reliable research-based data.
To help the family deal with the delirium of their dying relative, the nurse can suggest that they should:
a. stimulate the patient with music and visits from friends.
b. talk to the patient in quiet tones.
c. sit quietly in the room with the patient.
d. speak firmly to the patient to bring him back to reality.
B
Talking with the patient is comforting to the patient. Even when unresponsive, patients can hear. Stimulation is not helpful and may confuse the patient further.
The nurse understands that an expected outcome should be: (Select all that apply.)
a. realistic.
b. approved by the health care provider.
c. attainable.
d. within a defined time.
e. included after patient collaboration.
ACDE
An expected outcome should be realistic and attainable and should have a defined time line after collaboration with the patient.
The nurse should make a point when closing the initial interview to: (Select all that apply.)
a. develop rapport.
b. summarize the problems discussed.
c. thank the patient for his or her time.
d. discuss the nursing goals associated with nursing diagnoses.
e. give a copy of the nursing care plan to the patient.
BC
The nurse should summarize the problems discussed, thank the patient for his or her time, and explain what happens next and when the nurse will return.