Key Words
The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse?
1. Manager
2. Educator
3. Advocate
4. Caregiver
4
The nurse is practicing basic nursing skills. Some of the tasks can be delegated, but the nurse chose to perform them, so the nurse is acting as a caregiver. A manager coordinates the care of a client, an educator teaches a client, and an advocate upholds a client's rights.
The nurse witnesses an automobile crash on a highway and stops to provide assistance to the victim. The nurse notes that the client has sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the crash. Which is accurate regarding the nurse's immunity from this suit?
1. The Good Samaritan law will protect the nurse.
2. The Good Samaritan law will not protect the nurse.
3. The Good Samaritan law protects laypersons but not professional primary health care providers (PHCPs).
4. The Good Samaritan law will provide immunity from the suit, even if the nurse has accepted compensation for the care provided.
1
A Good Samaritan law is passed by a state legislature to encourage nurses and other PHCPs to provide care to a person when an accident, emergency, or injury occurs without fear of being sued for the care provided. Its protection lies in the inability to sue the nurse or other PHCP for negligence in the care provided at the scene of the accident or during the emergency, even if further injury occurred because of the PHCP's care. Called immunity from suit, this protection usually applies only if all conditions of the law are met, such as that the PHCP received no compensation for the care provided and the care given was not willfully and wantonly negligent.
The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get out of bed.
3
The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.
A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?
1. Call the client's family to arrange for transportation.
2. Contact the client's primary health care provider (PHCP).
3. Attempt to persuade the client to stay "for only a few more days."
4. Tell the client that leaving would likely result in an involuntary commitment.
2
In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.
The nurse should instruct the assistive personnel (AP) to avoid the use of a straight razor for which client?
1. The postoperative client
2. The client taking warfarin
3. The client with an infection
4. The client taking acetaminophen
2
Warfarin is an anticoagulant, which places the client at risk for bleeding. Use of a straight razor increases the risk of abrasion and bleeding because of the client's ineffective clotting capability. Postoperative status, infection, and taking acetaminophen are not affected by the choice of shaving tools
A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation?
1. Assault
2. Battery
3. Slander
4. Invasion of privacy
1
Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result from the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.
A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
1. "I will sign as a witness to your signature."
2. "You will need to find a witness on your own."
3. "Whoever is available at the time will sign as a witness for you."
4. "I will call the nursing supervisor to seek assistance regarding your request."
4
Instructional directives (living wills) are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.
The nurse has made an error in documenting an assessment finding in the client's record. What action should the nurse take to correct the error?
1. Write the late entry in the client's record.
2. Erase the error and rewrite the correct data.
3. Use white correction fluid or tape to cover the error and write in the correct assessment findings.
4. Draw a line through the error, initial and date the line, and then provide the correct information.
4
If the nurse makes an error in documenting in the client's record, the nurse should follow agency policies to correct the error. This includes drawing 1 line through the error, initialing and dating the line, and then providing the correct information. Erasing data from the client's record and using white correction fluid or tape are prohibited. A late entry is used to document additional information not remembered at the initial time of documentation. Procedures for correcting an error via the use of electronic documentation may be different, and the nurse should follow agency guidelines.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
1. Obtain a court order for the surgical procedure.
2. Ask the EMS team to sign the informed consent.
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family
3
In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?
1. Refuse to float to the ICU based on lack of unit orientation.
2. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.
3. Ask the nursing supervisor to review the hospital policy on floating.
4. Submit a written protest to nursing administration, and then call the hospital lawyer.
2
Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.
Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort?
1. Libel
2. Slander
3. Assault
4. Negligence
2
Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.
The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
1. Call security.
2. Call the police.
3. Call the nursing supervisor.
4. Lock the coworker in the medication room until help is obtained
3
Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.
Which of the following are not appropriate documentation in a client's chart: select all that apply:
1. "will continue to monitor."
2. "incident report filled out."
3. "client ambulated with physical therapy stating 6/10 pain"
4. "client sleeping eyes closed."
5. "client offered breakfast, tolerated 50% of meal before reporting nausea."
6. "client angry"
1, 2, 4, 6
NEVER document future tense, incident reports are own documentation not for chart, 4 can be misinterpreted as a patient being dead, 6 is interpreting subjective not objective information
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?
1. "I cannot discuss any client situation with you."
2. "If you want to know about Carol, you need to ask her yourself."
3. "Only because you're worried about a friend, I'll tell you that she is improving."
4. "Being her friend, you know she is having a difficult time and deserves her privacy."
1
The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.
The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)?
1. Determining if the client has consistently been medication compliant
2. Providing distraction for the client by engaging the client in a board game
3. Discussing the frequency and duration of the hallucinations with the client
4. Assisting the client in identifying any new stressors he or she may be experiencing
2
Although all of the options represent appropriate interventions, APs are permitted only to engage the client in a distraction such as a board game, and so it is an intervention that the nurse may delegate after sufficiently instructing the AP. The other options, assessing medication compliance, the characteristics of the hallucinations, and stressors, are nursing responsibilities and may not be delegated to a AP.
The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?
1. "Autonomy is the fundamental right of each and every client."
2. "A client's rights are guaranteed by both state and federal laws."
3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights."
4. "Regardless of the client's condition, all nurses have the duty to value client rights."
3
The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights. While it is true that autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for the concept.
An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
1. "Oh, really? I will discuss this situation with your son."
2. "Let's talk about the ways you can manage your time to prevent this from happening."
3. "Do you have any friends who can help you out until you resolve these important issues with your son?"
4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
4
The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.
Which identifies accurate nursing documentation notation(s)? Select all that apply.
1. The client is in bed snoring and sleeping.
2. Abdominal wound dressing is dry and intact without drainage.
3. The client seemed angry when awakened for vital sign measurement.
4. The client appears to become anxious when it is time for respiratory treatments.
5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
2 and 5
Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.
The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care?
1. The informed consent does not need to be obtained.
2. The informed consent should be obtained from the family.
3. The informed consent needs to be obtained from the client.
4. The primary health care provider will provide the informed consent.
3
Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.
1. Open doors to client rooms.
2. Move beds away from windows.
3. Close window shades and curtains.
4. Place blankets over clients who are confined to bed.
5. Relocate ambulatory clients from the hallways back into their rooms.
2, 3, 4
In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.
The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.
1. Libel
2. Battery
3. Assault
4. Slander
5. False imprisonment
2, 3, 5
False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the client.
The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply.
1. Respect assumptions.
2. Monitor language and tone.
3. Adopt a "need-to-know" policy.
4. Be alert to the presence of gossip.
5. Try to limit the use of obscene language.
6. Hold yourself and one another accountable.
2, 3, 4, 6
Some ethical strategies to use when preparing a change-of-shift report include the following: monitoring language and tone, adopting a "need-to-know" policy, being alert to the presence of gossip, and holding oneself and one another accountable. Respecting assumptions and limiting the use of obscene language are not appropriate strategies. A change-of-shift report is given from 1 caregiver to another caregiver who is taking on responsibility for the client's care to ensure continuity of care.
The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.
1. Document a late entry in the client's record.
2. Draw 1 line through the error, initialing and dating it.
3. Try to erase the error for space to write in the correct data.
4. Use whiteout to delete the error to write in the correct data.
5. Write a concise statement to explain why the correction was needed.
6. Document the correct information and end with the nurse's signature and title.
2, 6
If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing 1 line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary.
Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? Select all that apply.
1. "This document is a separate document from my final will."
2. "This document is strictly for indicating if I want to be resuscitated."
3. "I need to have my family sign this document in case my condition worsens."
4. "This document describes the kind of treatment I want depending on how sick I am."
5. "This document tells what I want and gives medical power of attorney to my doctor."
1, 4
An advance directive describes the specific medical treatment that a client wants if he or she is unable to make decisions about care. An advance directive is a separate document from the final will. The family does not need to sign an advance directive. Medical power of attorney is a type of advance directive but requires separate documentation. A do not resuscitate order is a type of advance directive, but an advance directive encompasses additional information. Therefore, options 2, 3, and 5 are incorrect.
The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply.
1. The client receiving a heparin infusion
2. The client receiving a blood transfusion
3. The client receiving continuous oxygen at 2 L/min
4. The client recovering from Guillain-Barré syndrome
5. The client who just returned from surgery for a hip repair
6. The client on isolation for methicillin-resistant Staphylococcus aureus
3, 4, 6
APs cannot be assigned to a client requiring care that is more than basic. APs do not have the education to safely care for clients requiring more than basic care. Assigning a AP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN).