Which identifies accurate nursing documentation notations? select all that apply.

Call the nursing supervisor.

18)A hospitalized client tells the nurse that an instructional directiveis being prepared and that the lawyer will be bringing the document to the hospitaltoday for witness signatures. The client asks the nurse for assistance in obtaining awitness to the will. Which is themost appropriateresponse to the client?

18)The nurse has made an error in a narrative documentation of anassessment finding on a client and obtains the client's record to correct theerror. The nurse should take which actions to correct the error?Select allthat apply.

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Document the correct information and end with the nurse's signatureand title.Draw 1 line through the error, initialing and dating it.19)Which identifies accurate nursing documentation notations?Select all thatapply.

20)A nursing instructor delivers a lecture to nursing students regarding the issue ofclient's rights and asks a nursing student to identify a situation that represents anexample ofinvasion of client privacy. Which situation, if identified by the student,indicates an understanding of a violation of this client right?

21)Nursing staff members are sitting in the lounge taking their morning break. Anunlicensed assistive personnel (UAP) tells the group that she thinks that the unitsecretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell thenursing staff that the secretary probably contracted the disease from her husband,who is supposedly a drug addict. The registered nurse should inform the UAP thatmaking this accusation has violated which legal tort?

22)An 87-year-old woman is brought to the emergency department for treatmentof a fractured arm. On physical assessment, the nurse notes old and new ecchymoticareas on the client's chest and legs and asks the client how the bruises weresustained. The client, although reluctant, tells the nurse in confidence that her sonfrequently hits her if supper is not prepared on time when he arrives home from work.Which is themost appropriatenursing response?

1. 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?
   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 client was found lying on the floor.

2. 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. Transport the victim to the operating room for surgery.

3. 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 action first?
   1. Call the hospital lawyer.
   2. Refuse to float to the ICU.
   3. Call the nursing supervisor.
   4. Identify tasks that can be performed safely in the ICU.

   4. Identify tasks that can be performed safely in the ICU.

4. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker 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 co-worker in the medication room until help is obtained.

   3. Call the nursing supervisor.

5. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will 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. "I will call the nursing supervisor to seek assistance regarding your request."

6. 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 action to correct the error?
   1. Documenting a late entry into the client's record
   2. Trying to erase the error for space to write in the correct data
   3. Using whiteout to delete the error to write in the correct data
   4. Drawing one line through the error, initialing and dating, and then documenting the correct information

   4. Drawing one line through the error, initialing and dating, and then documenting the correct information

7. Which identifies accurate nursing documentation notations? Select all that apply.
   1. The client slept through the night.
   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.

   • 1. The client slept through the night.
   • 2. Abdominal wound dressing is dry and intact without drainage.
   • 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

8. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?
   1. Performing a procedure without consent
   2. Threatening to give a client a medication
   3. Telling the client that he or she cannot leave the hospital
   4. Observing care provided to the client without the client's permission

   4. Observing care provided to the client without the client's permission

9. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) 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. Which legal tort has the UAP violated?
   1. Libel
   2. Slander
   3. Assault
   4. Negligence

   2. Slander

10. 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 that 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. "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."

11. The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?
    1. Contact the nursing supervisor.
    2. Administer the dose prescribed.
    3. Withhold the medication until the HCP can be contacted.
    4. Administer the recommended dose until the HCP can be located.

    1. Contact the nursing supervisor.

12. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate nursing action?
    1. Call the police.
    2. Cut up the photograph and throw it away.
    3. Call the nursing supervisor and report the incident.
    4. Call the laboratory and ask for the individual's name who sent the photograph.

    3. Call the nursing supervisor and report the incident.

13. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP?
    1. Ignore the resistance.
    2. Exert coercion on the UAP.
    3. Provide a positive reward system for the UAP.
    4. Confront the UAP to encourage verbalization of feelings regarding the change.

    4. Confront the UAP to encourage verbalization of feelings regarding the change.

14. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?
    1. Using sterile sheets and linens
    2. Performing strict handwashing technique
    3. Wearing gloves and a gown only when giving direct care to the client
    4. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

    3. Wearing gloves and a gown only when giving direct care to the client

15. 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. Contact the client's health care provider (HCP).
    2. Call the client's family to arrange for transportation.
    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.

    1. Contact the client's health care provider (HCP).

16. The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the most appropriate nursing response?
    1. "No, I won't tell anyone."
    2. "I cannot promise to keep a secret."
    3. "It depends on what the secret is about."
    4. "If you tell me the secret, I may need to document it."

    2. "I cannot promise to keep a secret."

17. 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. "I cannot discuss any client situation with you."

18. The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while 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. Battery
    • 3. Assault
    • 5. False imprisonment

19. Which statement demonstrates the bestunderstanding 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 respect client rights."

    3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights."

20. The nurse is caring for a client who was involuntarily hospitalized 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?
    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 health care provider will provide the informed consent.

    3. The informed consent needs to be obtained from the client.

21. A client has refused to eat more than a few spoonfuls of breakfast. The 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 had been losing weight for 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

22. A client has refused to eat more than a few spoonfuls of breakfast. The 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 been losing weight for 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 to cry and tries to eat more. Based on the nurse's actions, the nurse may be accused of which legal tort?
    1. Assault
    2. Battery
    3. Slander
    4. Invasion of privacy

    1. Assault

23. A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths?
    1. "They are developed based on appropriate standards of care."
    2. "They are nursing care plans and use the steps of the nursing process."
    3. "They are developed through the collaborative efforts of members of the health care team."
    4. "They provide an effective way for monitoring care and for reducing or controlling the length of hospital stay for the client."

    2. "They are nursing care plans and use the steps of the nursing process."

24. 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 health care providers (HCP).
    4. The Good Samaritan Law will provide immunity from the suit, even if the nurse has accepted compensation for the care provided.

    1. The Good Samaritan Law will protect the nurse.

25. A nurse manager is planning to implement a change in the nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance during the change process. Whichprimary technique should the nurse use in implementing this change?
    1. Introduce the change gradually.
    2. Use coercion to implement the change.
    3. Manipulate the participants in the change process.
    4. Confront the individuals involved in the change process.

    1. Introduce the change gradually.

26. The registered nurse (RN) is observing a licensed practical nurse (LPN) who is caring for a client with a uterine tumor who had a vaginal hysterectomy. The RN should intervene if the RN notes the LPN performing which action?
    1. Assisting the client to ambulate
    2. Elevating the knee gatch on the client's bed
    3. Performing range-of-motion exercises to the client's legs
    4. Removing the antiembolism stockings during morning care

    2. Elevating the knee gatch on the client's bed

27. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action?
    1. Using a Z-track method for injection
    2. Massaging the injection site after injection
    3. Preparing an air lock when drawing up the medication
    4. Changing the needle after drawing up the dose and before injection

    2. Massaging the injection site after injection

28. The nurse employed in a surgical unit in a hospital arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is appropriate?
    1. Refuse to float to pediatrics.
    2. Convince another nurse to float to the pediatric unit.
    3. Tell the supervisor that she needs to go home because of illness.
    4. Call the nursing supervisor to discuss the request to report to pediatrics.

    4. Call the nursing supervisor to discuss the request to report to pediatrics.

29. The nurse is acting in the role of client advocate in which situations? Select all that apply.
    1. Promoting client comfort
    2. Demonstrating mutual respect for all nurses
    3. Questioning health care provider prescriptions
    4. Supporting a client decision regarding a health care choice
    5. Speaking at a continuing education offering in the community

    • 1. Promoting client comfort
    • 3. Questioning health care provider prescriptions
    • 4. Supporting a client decision regarding a health care choice

30. A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance?
    1. A client is performing colostomy irrigations.
    2. The client with a leg ulcer is demonstrating signs of wound healing.
    3. A postoperative client is discharged home 1 day earlier than expected.
    4. The client with diabetes mellitus is administering insulin injections appropriately.

    3. A postoperative client is discharged home 1 day earlier than expected.

31. A nurse calls a client's health care provider (HCP) to report that the client, who has heart failure, is demonstrating increased wheezes on lung auscultation and dyspnea. The HCP is in a hurry because of involvement in a critical care situation in the hospital emergency department and gives the nurse a telephone prescription for furosemide (Lasix). Afterward the nurse realizes that the route of the medication is unclear. Which would be the appropriate action by the nurse?
    1. Call the HCP who gave the telephone prescription and clarify the prescription.
    2. Call the nursing supervisor for assistance in determining the route of the medication.
    3. Administer the medication by the intravenous route because this route usually is used for clients with heart failure.
    4. Administer the medication by the oral route, and clarify the prescription once the HCP has finished addressing the critical care issue in the emergency department.

    1. Call the HCP who gave the telephone prescription and clarify the prescription.

32. The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication?
    1. Wash the burn site.
    2. Apply 1/16-inch film directly to the burn sites.
    3. Apply the medication with a sterile gloved hand.
    4. Apply saline-soaked dressings over the medication.

    4. Apply saline-soaked dressings over the medication.

33. A health care provider (HCP) asks the nurse to discontinue tube feeding in a client who has a terminal condition. The HCP tells the nurse that the request was made by the client's spouse and children. What should the nurse check for first before carrying out the prescription?
    1. Court approval to discontinue the treatment
    2. Approval by the institutional ethics committee
    3. A written prescription by the HCP to remove the tube
    4. Authorization by the family to discontinue the treatment

    4. Authorization by the family to discontinue the treatment

34. After initial assessment the nurse determines the need to place a restraint on a client. The client refuses application of the restraint. What is the best nursing action for this client?
    1. Apply the restraint anyway.
    2. Contact the health care provider (HCP).
    3. Compromise with the client and then apply the restraint.
    4. Medicate the client with a sedative, and then apply the restraint.

    2. Contact the health care provider (HCP).

35. While eating lunch in the hospital cafeteria, a nursing student overhears two nurses talking about a client. The student understands which fact about confidentiality?
    1. Talking about clients in public places is a violation of the client's confidentiality.
    2. The client's rights to confidentiality do not apply to the break time of employees.
    3. It is acceptable for the nurses to talk about a client because they are on the same treatment team.
    4. The nurses taking care of the client should not share information that the client has told them with each other.

    1. Talking about clients in public places is a violation of the client's confidentiality.

36. Which statement would be considered a judgmental statement?
    1. "I don't think you need to do that."
    2. "Tell me about making that decision."
    3. "I would like to be sure I understood."
    4. "When did you first notice you felt that way?"

    1. "I don't think you need to do that."

37. A woman with left-sided weakness needs assisted living. The woman's family plans to sell her home to pay for assisted living, but the woman refuses to sell because she feels that her family should pay the expenses. What should the nurse do at this time?
    1. Carefully explain the woman's wishes to the family.
    2. Ask the woman to share experiences about the house.
    3. Arrange a meeting between the children and the woman.
    4. Suggest using a power of attorney to deal with the children.

    2. Ask the woman to share experiences about the house.

38. The registered nurse is beginning a new job in a clinic and attends an orientation session. After the session, another new employee asks the registered nurse to describe case management, a component of the discussions in the orientation session, because the employee did not clearly understand the concept. The registered nurse responds by making which statement?
    1. "Case management is an important concept, but it doesn't promote appropriate use of personnel."
    2. "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care."
    3. "Case management saves money for the institution because clients with similar problems are all treated in the same manner."
    4. "Case management requires an experienced nurse because it represents a primary health prevention focus and is managed by a single nurse."

    2. "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care."

39. The community health nurse is working with disaster relief personnel after a hurricane that ruined many homes in the local community. The nurse is working to find housing for the survivors and is organizing counseling services. Which prevention level does the nurse's actions represent?
    1. Primary
    2. Secondary
    3. Tertiary
    4. Quaternary

    3. Tertiary

40. 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. Caregiver

41. A client refuses to take a medication. Which would be the most therapeutic response by the nurse?
    1. "I'll come back later to see if you have changed your mind."
    2. "You don't have to take the medication if you don't want to."
    3. "This medication is going to help you get better, why don't you go ahead and take it?"
    4. "Do you want me to call your health care provider (HCP) and tell him you won't take your medication?"

    2. "You don't have to take the medication if you don't want to."

42. The experienced nurse is observing a newly hired graduate nurse count opioids as part of the orientation process. The experienced nurse determines that the newly hired nurse needs further teaching about the procedure for counting opioids when which statement is made?
    1. "Any discrepancies in a count will be reported immediately."
    2. "I will record each dispensing of an opioid on the special opioids inventory record."
    3. "If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift."
    4. "Opioids will be counted each time one is removed from the drawer and at the end and beginning of each shift."

    3. "If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift."

43. The nurse is working at a computer in the nurses' station when the charge nurse from another nursing unit approaches and asks about the condition of the client in room 432, stating, "The client is my neighbor and I want to check on her." The nurse should make which most appropriate response?
    1. "I'm sorry, I cannot tell you."
    2. "The condition of the client in room 432 is good."
    3. "You can get the information from the client's chart."
    4. "I don't think you should be asking me that question."

    1. "I'm sorry, I cannot tell you."

44. 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. "This document is a separate document from my final will."
    • 4. "This document describes the kind of treatment I want depending on how sick I am."

45. The nurse suspects that a client is not fully aware of the implications of a procedure and the client is about to sign an informed consent. What action would be most appropriate for the nurse to take?
    1. Ask the client if the doctor explained the procedure before obtaining the signature.
    2. Ask a family member to sign the consent because the client seems unsure at this time.
    3. Tell the client that he can ask the doctor for more details when he gets to the operating room.
    4. Inform the health care provider that the client does not appear to fully understand the procedure and withhold obtaining the signature.

    4. Inform the health care provider that the client does not appear to fully understand the procedure and withhold obtaining the signature.

46. While making rounds a client asks the nurse, "What's wrong with that lady in the room next to me? She cries out all night long, and I hope she is okay." What is the nurse's best response?
    1. "She's okay; she just gets confused at night."
    2. "I'm not allowed to say anything to you about her."
    3. "She has Alzheimer's disease and gets very upset because she is not home."
    4. "I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients."

    4. "I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients."

47. A client is scheduled for surgery, and the surgeon has explained the procedure and is about to obtain informed consent. Which statement by the client would indicate to the nurse that the client needs more information before giving informed consent to the procedure?
    1. "If I don't have this surgery, then the tumor will grow."
    2. "You said you will remove the tumor but will not be removing the entire breast."
    3. "I know my surgeon explained it, but I still don't know why surgery is needed."
    4. "I'll have some pain after the surgery, but it should get better with that tumor gone."

    3. "I know my surgeon explained it, but I still don't know why surgery is needed."

48. The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse should make which determination?
    1. That an informed consent does not need to be obtained
    2. That an informed consent should be obtained from the family
    3. That an informed consent needs to be obtained from the client
    4. That the health care provider will provide the informed consent

    3. That an informed consent needs to be obtained from the client

49. The nurse is caring for a client who has just returned from having a cystoscopy with biopsy. The nurse should intervene if an unlicensed assistive personnel (UAP) is observed taking which action?
    1. Obtaining the client's vital signs
    2. Assisting the client with repositioning in bed
    3. Telling the client that warm sitz baths may be prescribed
    4. Insisting that the client ambulate immediately after the procedure

    4. Insisting that the client ambulate immediately after the procedure

50. A nurse is caring for a client who has just returned from having a right-sided renal biopsy. The nurse should intervene if an unlicensed assistive personnel (UAP) is observed taking which action?
    1. Obtaining the client's vital signs
    2. Positioning the client on the left side
    3. Positioning the client on the right side
    4. Providing the client with reading materials

    2. Positioning the client on the left side

51. The nurse gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the health care provider to report the occurrence. Which action should the nurse anticipate?
    1. Incident will be reported to the board of nursing.
    2. Incident will be documented in the personnel file.
    3. The error will result in suspension and be written in the annual performance appraisal.
    4. The incident report will be used to review quality of care and determine potential risks.

    4. The incident report will be used to review quality of care and determine potential risks.

52. The nurse discovers a coworker in the linen closet injecting a medication into the antecubital area. Which most appropriate action should the nurse take?
    1. Call the police.
    2. Notify security.
    3. Call the nursing supervisor.
    4. Ignore what was discovered to avoid conflict.

    3. Call the nursing supervisor.

53. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response by the nurse is most appropriate?
    1. "I will need to sign as a witness to your signature."
    2. "It is your responsibility 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 for assistance regarding your request."

    4. "I will call the nursing supervisor for assistance regarding your request."

54. A 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 into 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 one line through the error, initial and date the line, and then provide the correct information.

    4. Draw one line through the error, initial and date the line, and then provide the correct information.

55. A nurse hears a client calling out for help and finds the client lying on the floor. The nurse performs an assessment and assists the client back to bed. The health care provider is notified of the incident, and the nurse completes an incident report. Which detail should the nurse document on the incident report?
    1. The client fell out of bed last night.
    2. The client climbed over the side rails.
    3. The client was found lying on the floor.
    4. The client was restless and tried to get up.

    3. The client was found lying on the floor.

56. An adult client is brought to the emergency department by emergency medical services after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which is the best initial action?
    1. Obtain a court order for the surgical procedure.
    2. Transport the victim to the operating room for surgery.
    3. Call the police to identify the client and locate the family.
    4. Ask the emergency medical services team to sign the informed consent.

    2. Transport the victim to the operating room for surgery.

57. The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse should take which priority action?
    1. Have the hospital chaplain sign the informed consent immediately.
    2. Send the client to surgery without the consent form being signed.
    3. Notify the health care provider to obtain a court order for the surgery.
    4. Obtain telephone consent from the family member witnessed by two clients.

    4. Obtain telephone consent from the family member witnessed by two clients.

58. The unit manager is reviewing documentation describing a client's progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control for the prior 48 hours. Who should the unit manager contact next?
    1. Assigned nurse to increase client care interventions
    2. Family to determine what is wrong and provide suggestions
    3. Health care provider and assigned nurse to determine measures to discharge the client
    4. Case manager to determine whether the predicted variance has been negotiated with the health insurer

    4. Case manager to determine whether the predicted variance has been negotiated with the health insurer

59. A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma?Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used.
    1. Evaluate the action.
    2. Verbalize the problem.
    3. Negotiate the outcome.
    4. Consider possible courses of action.
    5. Gather all of the information relevant to the case.
    6. Examine and determine one's own values on the issues.

    • 5. Gather all of the information relevant to the case.
    • 6. Examine and determine one's own values on the issues.
    • 2. Verbalize the problem.
    • 4. Consider possible courses of action.
    • 3. Negotiate the outcome.
    • 1. Evaluate the action.

Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?

Which information should the nurse include in a client's plan of care select all that apply?