Culture/Ethnicity
The role of the nurse regarding complementary and alternative medicine should include which action?
A. Advising the client about "good" versus "bad" therapies
B. Recommending herbal remedies that the client should use
C. Discouraging the client from using any alternative therapies
D. Educating the client about therapies that he or she is using or is interested in using
D. Educating the client about therapies that he or she is using or is interested in using
Rationale: Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role.
Which of the following organizations is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice?
A. National League for Nursing (NLN)
B. International Council of Nurses (ICN)
C. American Association of Colleges in Nursing (AACN)
D. American Nurses Association (ANA)
D. American Nurses Association (ANA)
As an advocate for the client, the nurse must make sure that "safe, effective care" is given in conformity with the:
A. Nurse Practice Act (NPA).
B. American Nursing Association (ANA)
C. National Council for Licensure Examinations
D. State Board of Licensure
A. Nurse Practice Act (NPA).
Rationale: NPA is a state law passed by state's legislative body that define the practice of nursing and regulate nursing practice and defines the scope of nursing practice.
Which of the following is an inappropriate abbreviation by the Joint Commission?
A. QID
B. Q.I.D
C. ADL's
D. HOB
Rationale: The Joint Commission mandates appropriate abbreviations. Period's can be interpreted as decimals.
What are the five rights of delegation?
1. Right Person
2. Right Circumstance
3. Right Direction/Communication
4. Right Supervision
5. Right Task
The nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and should document which information?
A. The client believes the soul lives on after death.
B. Medication administration is not allowed.
C. Surgery is prohibited in this religious group.
D. The administration of blood and blood products is not allowed.
D. The administration of blood and blood products is not allowed.
Rationale: Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden.
Which is this an example of?
A. Mandated Reporting
B. Bioethics
C. Whistleblowing
D. Morals
C. Whistleblowing
Rationale: Whistleblowing is done in response to moral outrage and recognizing an unsafe situation. Can be internal or external.
Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following?
A. An unintentional tort
B. Assault
C. Invasion of Privacy
D. Battery
D. Battery
Rationale: Battery is the willful touching of a person without permission. Another name for an unintentional tort is malpractice. This situation is an intentional tort because the nurse executed the act on purpose.
Which are examples of appropriate medication orders? Select all that apply.
A.Lasix by mouth twice daily
B. Aspirin 325 mg by mouth every morning
C. Tylenol 500 mg prn
D. Rocephin 200 mg IV q6h
E. Ibuprofen 200 mg q4h prn fever or mild pain
Answer: B, D
Rationale: Remember five rights of medication.
Which of these task's can we delegate to an UAP? Select all that apply.
A. Sterile dressing change on a stable patient.
B. Vital's on postoperative patient
C. Perineal care on a stroke client
D. Perform Oral Hygiene on a patient who rates pain 5 out of 10.
E. Apply ointment on a geriatric patient.
C, D
Rationale:
A. Only LPN'S and RN'S can perform sterile dressing change.
B. This is an unstable patient.
C. UAP can perform perineal care on stable patients
D. This is a stable patient
E. UAP's cannot give medications
Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?
A. Pork roast, rice, vegetables, mixed fruit, milk
B. Crab salad on a croissant, vegetables with dip, potato salad, milk
C. Sweet and sour chicken with rice and vegetables, mixed fruit, juice
D. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea
C. Sweet and sour chicken with rice and vegetables, mixed fruit, juice
Rationale: Orthodox Judaism believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered.
Match the words with the right definitions.
A. Non-Maleficence
B. Fidelity
C. Altruism
D. Veracity
1. Concerned for the welfare and well-being of others.
2. Duty to tell the truth
3. Do not intentionally harm/ prevent harm
4. To keep a promise or vow/ to follow through
A = 3.
B = 4.
C = 1.
D = 2.
A 65 year-old hypertensive Muslim male patient was admitted two weeks ago. The nurse arrives to the client's bedside to perform a manual BP reading. The client states that he wants to go home today. The nurse is fearful the client may leave, so she left the patient in the blood pressure cuff upon exiting the room to document the client's statement.
What is this an example of?
Rationale: False imprisonment generally refers to the confinement of a person without the consent of such person or without legal authority.
A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response?
A. "I'm sorry, but patients are not allowed to copy their medical records."
B. "I can make a copy of your record for you right now."
C. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules."
D. "I will need to check with our records department to get you a copy."
D. "I will need to check with our records department to get you a copy."
Which leadership style is most appropriate in emergency situations?
A. Laissez-Faire
B. Authoritative
C. Democratic
B. Authoritative
The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response?
A. "It is a process of learning a different culture to adapt a new or changing environment."
B. "It is a subjective perspective of the person's heritage and a sense of belonging to a group."
C. "It is a group of individuals in a society who are culturally distinct and have a unique identity."
D. "It is a group that shares some of the characteristics of the larger population group of which it is a part."
A. "It is a process of learning a different culture to adapt a new or changing environment."
Rationale: Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option 2 describes ethnic identity. Option 3 describes an ethnic group. Option 4 describes a subculture.
Match the examples with the professional nursing code of ethics:
A. Advocacy
B. Responsibility
C. Accountability
D. Confidentiality
1. You see an open medical record on the computer and close it so no one else can read the record without proper access.
2. You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the primary care provider and your head nurse and follow agency procedure.
3. A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request.
4. You tell your patient that you will return in 30 minutes to give him his next pain medication.
1 = D
2 = C
3 = A
4 = B
A pregnant woman at 15 weeks’ gestation is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn’t fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse’s role in obtaining informed consent? Select all that apply.
A. Explain the risks and benefits associated with the procedure
B. Describe alternatives to the procedure.
C. Witness the client’s signature on the consent form.
D. Advocate for the client by ensuring she is making an informed decision.
Answer: C, D
(1) It is the physician’s duty to provide information to the client-related to risks and benefits. (2) It is the physician’s duty to provide information to the client related to alternatives. (3) CORRECT: One of the nurse’s roles in the informed consent process is to witness the signature on the consent form. (4) CORRECT: One of the nurse’s roles in the informed consent process is to advocate for the client by ensuring she has been provided the necessary information to make an informed decision.
A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation?
A. Erase or use correcting fluid to completely delete the error.
B. Draw a single line through the entry and rewrite it above or beside it.
C. Use a permanent marker to block out the mistaken entry and rewrite it.
D. Remove the page with the error and rewrite the data on that page correctly
B. Draw a single line through the entry and rewrite it above or beside it.
What is the purpose of the SBAR?
A. To provide communication during client rounding
B. To provide shift-to-shift reports between patients
C. To document care in the client's chart
D. To provide consistent communication when there is a change in a client's condition
D. To provide consistent communication when there is a change in a client's condition
Which client(s) has a high risk of obesity and diabetes mellitus? Select all that apply.
A. A 40-year-old Latino American man.
B. A 45-year old Native American woman.
C. A 23-year-old Asian American woman.
D. A 35-year-old Hispanic American woman.
E.. A 40-year-old African American woman.
Answer: 1, 2, 4, 5
Rationale: Because of their health and dietary practices. Native Americans, Latino Americans, Hispanic Americans, and African Americans have a high risk of obesity and diabetes mellitus.
What are the correct steps to resolve an ethical dilemma on a clinical unit? Place the steps in correct order.
1. Clarify values.
2. Ask the question, Is this an ethical dilemma?
3. Verbalize the problem.
4. Gather information.
5. Identify course of action.
6. Evaluate the plan.
7. Negotiate a plan
2, 4, 1, 3, 5, 7, and 6
A 52 year old unemployed and uninsured client arrives at the Emergency Department of the local private hospital closest to home with a head laceration, showing signs and symptoms of disorientation, dyspnea, and distress. The triage nurse calls the on-call provider, who instructs the nurse to send the client to the county hospital several blocks away. What federal law protects this client against refusal of care at the private hospital?
What is EMTALA.
Rationale: Emergency Medical Treatment and Active Labor Act mandates health care facilities provide emergency medical treatment to clients seeking emergency health care regardless of their ability to pay, legal status, or citizenship status.
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 health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?
A. The client fell out of bed
B. The client climbed over the side rails
C. The client was found lying on the floor
D. The client became restless and tried to get out of bed.
C. The client was found lying on the floor
Rationale: The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, 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.
Regarding research and nursing care, the ANA expects that all nurses will:
A. Report findings to clients.
B. Integrate research findings into care.
C. Improve assessment skills.
D. Create research questions.