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 & 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 & tried to get out of bed.
3. The client was found lying on the floor
Rational: The incident report should contain the client's name, age & 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. Option 1, 2 & 4 are interpretations of the situation & ARE NOT FACTUAL INFORMATION OBSERVED BY THE NURSE.
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 & the client has sustained a severe head injury & multiple fractures & unconscious. An emergency craniotomy is required. Regarding information 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 & locate the family
3. Transport the victim to the operating room for surgery
Rationale: in general, there are 2 situations in which informed consent of an adult client is not needed. One is when an emergency is present & delaying treatment for the purpose of obtaining informed consent. Option 1 will delay emergency treatment, option 2 is inappropriate. Although 4 may be pursued, it is not the best action.
The nurse has just assisted a client back to bed after fall. The nurse & health care provider have assessed the client & have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
1. Reassess the client
2. Conduct a staff meeting to describe the fall
3. Document in the nurse's notes that an incident report was completed
4. Contact the nursing supervisor to update information regarding the fall.
1. Reassess the client
Rationale: After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information & shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes if the nursing supervisor will contact the nurse if status update is necessary.
The nurse arrives at work & is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed & 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. Refusal 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
Rationale: Floating is an acceptable legal 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 & identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.
The nurse who works on the night shift enters the medication room & finds a co-worker w/ 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
Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing & may develop plans for treatment & supervision of the impaired nurse. This incident NEEDS TO BE REPORTED TO THE NURSING SUPERVISOR, who will then report to the board of nursing & other authorities, such as the police, as required. The nurse may call security if disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate & unsafe action.
A hospitalized client tells the nurse that a living will is being prepared & 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 APPROPIATE 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 signature."
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."
Rationale: Living wills, also known as natural death acts in some states, are required to be in writing & signed by the client. The client's signature must be witnessed by specified individualized or notarized. Laws & guidelines regarding living wills 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 non therapeutic & not a helpful response. The should seek the assistance of the nursing response.
The nurse has made an error in a narrative documentation of an assessment finding on a client & obtain 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 & dating, and then documenting the correct information.
4. Drawing one line through the error, initialing & dating, and then documenting the correct information.
Rationale: If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error, initialing & dating the line, & then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record & the use of whiteout are prohibited.
Which identifies accurate nursing documentation notations? Select all that apply.
1. The client slept through the night.
2. Abdominal wound dressing is dry & 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 & intact without drainage.
5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema
Rationale: 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.
A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights & 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 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
Rationale: Invasion of privacy occurs w/unreasonable intrusion into an individual's private affairs. performing a procedure w/out consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.
An 87 year old women is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old & new ecchymotic areas on the client's chest & 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 & help you 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 & help you find a safe place for you to stay."
Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds & other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed w/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 legal implications of the situation and do not ensure a safe environment for the client.
The nurse calls the health 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. Hold medication until the HCP can be contacted
4. Administer the recommended dose until the HCP can be located.
3. Hold medication until the HCP can be contacted
Rationale: The HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. UNDER NO CIRCUMSTANCES SHOULD THE NURSE PROCEED TO CARRY OUT THE PRESCRIPTION UNTIL OBTAINING CLARIFICATION.
The nurse employed in a hospital is waiting to receive a report from the laboratory via the fax machine. The fax machine activates & 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 & throw it away
3. Call the nursing supervisor & report the incident
4. Call the laboratory & ask for the individual's name who sent the photograph.
3. Call the nursing supervisor & report the incident
Rationale: Ensuring a safe workplace is responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date & open displays of transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 & 4 are in appropriate initial actions.
I have not reviewed these yet for error....
I have not reviewed these yet for errors....