LEADERSHIP AND MANAGEMENT PART 2

Question 1

The emergency department (ED) triage nurse is assigned to see the following clients. Which of the following clients requires the most rapid action in the ED?

A. A travel blogger who needs tuberculosis testing after exposure to a person with TB during his trip.

B. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection.

C. A pregnant woman with a blister-like rash on the face and is possibly having varicella.

D. An infant with a runny nose and whose older brother has pertussis.

Answer 1

Explanation

The Correct Answer is C.

The primary responsibility of the triage nurse is to perform an initial nursing assessment and determine which patient(s) require immediate care or isolation. The triage nurse should be able to identify patients who pose a potential risk to others by being familiar with commonly occurring illnesses/infections. Emergency department nurses and triage nurses must be adept at prioritization.

Prioritization refers to a concept of deciding which duties/ clients require immediate attention and which ones could be delayed until later. None of the clients in the options above show any signs of unstable vitals. Therefore, the safety of the client and other clients takes priority.

Chickenpox (Varicella) is transmitted airborne, and that can be easily transferred to the other clients in the emergency unit. The pregnant woman with suspected Varicella rash (Choice C) should be isolated right away from other clients through placement in a negative-pressure room.

Choice A is incorrect. The client who has been exposed to Tuberculosis (TB) does not place the other clients at risk for infection because he/ she has no symptoms of active TB. Latent tuberculosis is not infectious by itself. Pulmonary/ Cavitary disease can manifest with a productive cough and carries the highest risk of infection. Only such symptomatic TB patients should be placed in a negative-pressure room with airborne isolation precautions.

Choices B and D are incorrect. Droplet precautions should be instituted for the client with possible pertussis. Contact isolation should be implemented for the client with a history of MRSA infection. But these two patients should be attended after isolating the pregnant client with possible varicella because the risk of infectivity with the airborne transmission is much higher.
NCSBN Client Need
Topic: Management of care; Sub-topic: Establishing priorities; Apply knowledge of pathophysiology when establishing priorities for interventions with multiple clients.

Question 2

While working in a same-day surgery department, a nurse is witnessing the patient signing the consent form for his gastric bypass surgery. The surgeon asks the patient if they have any further questions, and the patient says no. After the surgeon leaves, the patient begins asking the nurse questions about the surgery and the possible complications. He states, “I don’t know if I should do this. What do you think?”. What are the appropriate responses from the nurse? Select all that apply.

A. “That is up to you, what do you want to do?”

B. “It sounds like you still have some concerns about the operation, is that correct?”

C. “Let me call the surgeon and have him come back in. He can go over these concerns with you so that you understand everything clearly.”

D. “I wouldn’t do it, this surgery sounds risky!”

Answer 2

Explanation

A is incorrect. While it is appropriate to encourage the patient to make their own choices, this is not a therapeutic response. Furthermore, it is the nurse’s responsibility to ensure that if the client does not fully understand everything after they have signed the informed consent, the surgeon comes back to clarify. It is the surgeon’s responsibility to explain everything regarding the surgery, but it is the nurse’s responsibility to verify that they understand.

B is correct. This is a therapeutic response to the patient’s concerns as it validates how they are feeling and makes sure the nurse understands what they are saying. If the patient confirms that they have concerns about the operation, the surgeon should be called back to speak with them again.

C is correct. It is the nurse’s responsibility to ensure that if the client does not fully understand everything after they have signed the informed consent, the surgeon comes back to clarify. It is the surgeon’s responsibility to explain everything regarding the surgery, but it is the nurse’s responsibility to verify that they understand.

D is incorrect. This is not therapeutic, and it is inappropriate for the nurse to offer personal opinions to the patient.

NCSBN Client Need:

Topic: Management of CareSubtopic: Informed Consent

Reference:

Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 216

Question 3

You have just heard that a gunman is in your facility and is shooting at walls. What should you do before you get further instructions?

A. Close all the windows in the client’s rooms.

B. Close all the client’s doors to their rooms.

C. Do a horizontal evacuation of the clients to avoid this gunman.

D. Do a vertical evacuation of the clients to avoid this gunman.

Answer 3

Explanation

Choice B is correct. Active shooter (“Code Silver”) events are becoming increasingly common. The nurse should be aware of the best steps for survival when faced with an active shooter situation. Coordination of response with appropriate multi-disciplinary response partners is essential for succeeding in an active shooter situation. The key objectives are to protect the patients, visitors, and staff. Among the options listed, the most appropriate action is to close all the client’s doors to their rooms until you get further instructions from the security officers or the security department. Closing doors and hiding keeps clients out of the view of the gunman. If it’s safe to do so, evacuation can be carried out, but it’s important to have some idea regarding the gunman’s location before evacuating and coordinate with security personnel.

4As -refer to a 4-step process to prevent or reduce loss of life in an active shooter event:

Accept that an emergency is occurring. 
Assess what to do next depending on the location to save as many lives as possible
Act: Lockdown (lock and barricade the doors, turn off the lights, have patients get on the floor and hide) or evacuate if safe or when instructed by security personnel or fight back (last resort). 
Alert law enforcement and security.

Choice A is incorrect. The entry doors must be closed first, and the clients must be kept out of the view of the gunman. Closing all the windows may take longer, so the nurse should prioritize a more pertinent action.

Choices C and D are incorrect. Horizontal and Vertical evacuations are used during fire incidents. Horizontal evacuation refers to moving patients out of the area to another unit or section on the same floor, safely passing through the fire door. Vertical evacuation refers to moving patients downward away from a threat in the upper floors ( example; 5th floor to the 4th floor). Evacuation will be different during an active shooter situation than it would be for the fire. You would not do a horizontal or vertical evacuation of the clients to avoid this gunman when there is no clarity regarding the gunman’s location.

Reference: Sommer, Johnson, Roberts, Redding, Churchill, et al. Fundamentals for Nursing Edition; ATI Nursing Education.

Question 4

Your client has just been diagnosed with HIV/AIDS. The client is refusing their HIV/AIDS medications and is stating, “I do not have HIV/AIDS, and the laboratory has made a serious error.” Which of these nursing diagnoses is the most appropriate for this client, based on this refusal of medications and this client’s statement?

A. The lack of adherence to the medication regimen is related to the use of a psychological defense mechanism.

B. Ineffective coping is related to a laboratory error.

C. Knowledge deficit related to the need for HIV/AIDS medication.

D. The lack of compliance with the medication regimen is related to a knowledge deficit and laboratory errors.

Answer 4

Explanation

The correct answer is A. The most appropriate nursing diagnosis for this client is based on the refusal of medications. This client’s statement is “The lack of adherence to the medication regimen related to the use of a psychological defense mechanism.” This client uses denial as a psychological or ego defense mechanism to protect against the stressors associated with the diagnosis of HIV/AIDS.

Choice B is incorrect. “Ineffective coping related to a laboratory error” is not an appropriate nursing diagnosis for this client as based on this refusal of medications and this client’s statement because there is no evidence that a laboratory error has indeed occurred.

Choice C is incorrect. A “Knowledge deficit related to the need for HIV/AIDS medication” is not an appropriate nursing diagnosis for this client as it is based on the refusal of medications and this client’s statement because there is no evidence that this client does not understand the need for these medications.

Choice D is incorrect. “The lack of compliance with the medication regimen related to a knowledge deficit and laboratory errors” is not an appropriate nursing diagnosis for this client as based on this refusal of medications and this client’s statement because there is no evidence that this client does not understand the need for these medications or that an actual laboratory error has occurred.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, Sommer, Johnson, Roberts, Redding, Churchill et al. RN Mental Health Nursing, ATI Nursing Education and Videbeck, Sheila. Psychiatric-Mental Health Nursing.

Question 5

You are taking care of an 80-year-old patient who is post-op day one from abdominal surgery. Upon assessment, you notice bowel protruding through her incision and quickly determine that evisceration has occurred. Place the following actions in order of priority:
Call for help and stay with the patient
Cover the wound with a sterile normal saline dressing
Take vital signs and monitor for and signs of shock
Prepare the patient for immediate surgery
Document the incident.

Answer 5

Correct Answer is:
Call for help and stay with the patient
Cover the wound with a sterile normal saline dressing
Take vital signs and monitor for and signs of shock
Prepare the patient for immediate surgery
Document the incident.

Explanation

The priority of nursing action is to call for help but stay with the patient. The nurse should tell the person who responds to notify the surgeon immediately. This is a surgical emergency, and the surgeon must be notified STAT.

After help has been called, the nurse needs to cover the wound with a sterile 0.9% sodium chloride dressing. This helps prevent infection and keep the protruding organ moist and hydrated before surgery. The nurse should instruct the patient not to strain or cough, and keep the client in low Fowler’s position ( no more than 20 degrees bed elevation) with his/her knees flexed. This position relaxes abdominal muscles and reduces abdominal muscle tension.

After these two actions, the next nursing action is to check the patient’s vital signs and monitor for shock while waiting for the health care providers.If signs of shock such as tachycardia and hypotension are noted, there is a medical emergency, and the health care provider/ rapid response needs to be called to the bedside immediately.

After taking vital signs, the nurse should begin preparing the patient for immediate surgery. Lastly, after the patient has been taken to surgery, the nurse needs to document the incident.
NCSBN Client Need
Topic: Physiological Adaptation Subtopic: Medical Emergencies
Reference:
Ignatavicius D, Workman ML: Medical-surgical nursing: Patient-centered collaborative care, ed 7, Philadelphia.

Question 6

The nurse is caring for a patient following the placement of a gastrostomy tube. The Unlicensed Assistive Personnel (UAP) reports thin, pale, and yellow-green drainage with sour odor and a small amount of blood. Which is the best action for the nurse to take?

A. Obtain specimen for culture.

B. Assess the drainage.

C. Instruct UAP to obtain full set of patient’s vitals.

D. Assess patient’s temperature for fever.

Answer 6

Explanation

B is correct. The nurse should assess the patient’s drainage to confirm it is within the reasonable expectations for the patient’s condition. Up to 1500mL/day of thin, pale, yellow-green drainage with sour odor and a small amount of blood would be expected for this patient.

A is incorrect. There would be no reason to culture this drainage since it is within expectations for the patient’s condition.

C is incorrect. This would not be an indication to collect a unique set of vitals since this drainage is expected with the placement of a gastrostomy tube. If there is any doubt, the nurse should visualize and assess the patient, not delegate this task to the UAP.

D is incorrect. There would be no reason to expect the patient would be febrile since this drainage is usually scheduled with the gastrostomy tube.

NCSBN Client Need:
Topic: Management of care; Sub-Topic: Assignment/Delegation

Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 378)

Question 7

While admitting a patient, the nurse begins to review information regarding advanced directives. Still, the patient becomes agitated and refuses to discuss the issue or accept a handout about the topic. Which is the appropriate nursing action?

A. Leave the handout on the patient’s overbed table instructing him that he must review the content.

B. Document the patient’s refusal, using the patient’s own words, in quotes.

C. Explain to the patient that he must make decisions about accepting or refusing treatment while in the hospital.

D. Request an assessment of the patient’s competency related to making decisions about advanced directives.

Answer 7

Explanation

Correct Answer is B. While the Patient Self-Determination Act requires health care facilities to provide information about the patient’s right to refuse or accept treatment, the patient has the right to withdraw that information. Should the patient decline verbal and written information about advanced directives, the nurse should document that information was offered, and document the patient’s refusal, quoting the patient’s statements.

Choices A and C are incorrect - The patient has the right to autonomy and self-determination, to include refusing information regarding advanced directives. He is not required to have advanced instruction in place while in the hospital.

Choice D is incorrect – The patient’s refusal to accept information about advanced directives is not an indication of the patient’s level of competence.

Bloom’s Taxonomy – Analyzing
Reference:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8thEdition. Elsevier Mosby St Louis 2013.

Question 8

Upon entering the room, the nurse finds the patient lying on the floor appearing unresponsive. Which of the following should the nurse do first?

A. Initiate Code Blue.

B. Check if patient is breathing.

C. Assess carotid pulse.

D. Shout patient’s name and perform sternal rub.

Answer 8

Explanation

Choice D is correct.
Although the patient “appears” unresponsive, the “true unresponsiveness” can only be determined upon adequate assessment. Therefore, the first action the nurse should take is to check if the patient is alert/arousable. The nurse can assess this by shouting the patient’s name ( assessing response to verbal stimulation) and tapping the patient/ performing sternal rub ( assessing response to physical stimulation). If the patient is unresponsive despite these measures, the nurse should proceed to carry out other interventions. Among the focused assessment options provided in the options, assessing responsiveness is the fastest and the priority action.
Choice A, B, and C are incorrect. The nurse should first assess the patient before initiating a code blue ( Choice A). Following an assessment of the patient for responsiveness, the nurse should assess respiration/ breathing ( Choice B). If the patient is found to be unresponsive but breathing, the rapid response should be called. If the patient is not breathing, a code blue call should be initiated. Pulse must be assessed; however, the nurse’s correct sequence of actions is first to assess the patient’s responsiveness, then check for breathing, and then assess for the presence of a pulse.

Question 9

You are a nurse working in a medical unit with a trained aide. You have admitted a new patient and have received the following orders.You know that the correct prioritization for performing these tasks is: ( Please arrange in correct sequential order)
Insulin 2 units Humulin Subcutaneous now.
CBC, electrolytes, urinalysis, and 2 sets of blood cultures.
Vital Signs every 4 hours.
Amoxicillin 250 mg by mouth first dose now and then every 6 hours.

Answer 9

Correct Answer is:
Insulin 2 units Humulin Subcutaneous now.
CBC, electrolytes, urinalysis, and 2 sets of blood cultures.
Amoxicillin 250 mg by mouth first dose now and then every 6 hours.
Vital Signs every 4 hours.

Explanation

Correct Sequence is in the following order:-

Insulin – 2 units Humulin Subcutaneous NOW.
CBC, Electrolytes, urinalysis, and 2 sets of blood cultures
Amoxicillin 250 mg by mouth first dose now, and then every 6 hours
Vital Signs every 4 hours

While prioritizing the orders from physician, the nurse should look for the orders that specify urgency – such as “STAT” or “as soon as possible” or “now.”

A “now” prescription for insulin should be done as soon as possible after the patient arrives on the floor. The nurse should understand that insulin lowers the patient’s blood sugar and can help to prevent sequelae associated with high blood sugar. Since the patient is being initiated on antibiotics, it appears there is a suspicion of infection. In patients with suspected infection, glycemic control is helpful in achieving good outcomes.

Collecting the labs is the second task that should be completed since blood cultures have been ordered. Blood cultures must always be collected BEFORE the administration of an antibiotic so that the antibiotic does not interfere with the results. Obtaining cultures after antibiotics may give false negative results.

As soon as the blood cultures are drawn, the nurse should administer the amoxicillin since it is ordered “now”, and every 6 hours. In almost any infection including sepsis, guidelines allow 1 to 2 hours window from the time of patient arrival before which antibiotics can be administered. Blood cultures must be obtained before antibiotics.

Finally, vital signs are the lowest priority for the nurse since this is a task that can be delegated to the aide following an initial assessment. It can be executed after the above orders are completed.
NCSBN Client Need
Topic: Management of Care;Sub-Topic: Establishing Priorities
Subject: Adult Health;Lesson: Prioritization

Question 10

In a staff meeting, the nurses were asked by the nurse manager what their thoughts are on the solutions presented to them regarding medication errors. They were also asked to vote whether to apply the changes proposed or to veto it. Which management style is the unit practicing?

A. Autocratic

B. Democratic

C. Participative

D. Laissez-faire

Answer 10

Explanation

B is correct. In Democratic style management, staff members are encouraged to participate in the decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in this management style.

A is incorrect. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit.

C is incorrect. In a Participative management style, problems are identified by the manager and presented to the staff with several solutions. Staff members are encouraged to provide input however, the manager makes the final decision.

D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of management. The manager abdicates responsibility and decision making whenever possible in this type of management.

Reference

Nugent, P., et al., Mosby’s Comprehensive Review of Nursing

Question 11

An 82-year old man presents to the emergency department after a ground-level fall. The paramedics tell you that the left pupil was fixed and dilated. Upon arrival, the patient’s elbows, wrists, and fingers are flexed, and legs extended and rotated inward. What is the most important intervention for this patient?

A. Obtain IV access immediately

B. Turn patient on his side

C. Obtain accurate history from family

D. Take him straight to the CT scan

Answer 11

Explanation

Choice D is correct. This patient’s left pupil is fixed and dilated, which means it is not reactive to light and stays the same size. When this happens, it can be clinically inferred that there is a lesion or hemorrhage on the opposite (contralateral) side of the brain. The patient also exhibits decorticate (flexor) posturing, with elbows, wrists, and fingers flexed, and legs extended and rotated inward. Often, such abnormal posturing indicates severe brain damage. The patient sustained a fall, and these symptoms likely represent raised intracranial pressure due to intracranial hemorrhage. This patient needs to be taken straight to the CT department to obtain a CT scan of the brain. This will allow the physician to diagnose the patient and initiate early treatment.

Choice A is incorrect. Even though obtaining IV access is an important intervention, it is not the priority at this time. A non-contrast CT scan is usually the first intervention to detect a hemorrhage. Intravenous contrast is not necessary. The nurse can obtain IV access after the urgent CT scan is performed. Early diagnosis and appropriate treatment is critical in these settings.

Choice B is incorrect. If the patient started having a seizure, then he would need to be turned onto his side. However, he is posturing, which is not a seizure. There are two different types of posturing; decorticate and decerebrate. Decorticate looks as if the patient is turning his or her arms into the core of the body. Decerebrate looks like the patient’s arms are facing outwards, away from the body.

Choice C is incorrect. This intervention is important, especially to understand any events before arriving at the hospital, medications he is taking, and recent procedures he has had.

NCSBN Client Need I Topic: Physiological Adaptation; Sub-topic: Alterations in Body Systems

Reference: Lewis, Dirksen, Heitkemper, Bucher,

Question 12

The nurse checks the history of several pre-operative patients before their scheduled surgeries. Which of the following patients should the nurse be most concerned with and alert the doctor about the elevated risk of surgical complications? Select all that apply.

A. The epileptic patient who took carbamazepine early in the morning

B. The diabetic patient with a blood glucose of 250 mg/dl.

C. The patient with anemia and a hemoglobin level of 6.5mg/dl.

D. The patient who suffers from insomnia.

E. The patient who reports a history of trouble being anesthetized.

Answer 12

Explanation

Choices B and C are correct. The most concerning patients are diabetic patients with uncontrolled hyperglycemia and those with severe anemia. Both conditions significantly increase the patients’ risk of developing surgical complications and should be managed before surgery.

Hyperglycemia is an independent marker of poor surgical outcomes in both diabetic and non-diabetic patients. The random glucose test in an average adult normally ranges between 80mg/dl to 140mg/dl. A random blood sugar greater than 180 to 250 mg/dl is considered severe hyperglycemia. Uncontrolled hyperglycemia increases the risk of infections, delays surgical wound healing, prolongs hospital stay, and increases postoperative mortality. The physician must be notified, and the blood sugars must be optimized before surgical intervention. A desirable goal in most perioperative patients is to maintain blood glucose in the range of 140 to 180 mg/dl. In cases of severe hyperglycemia (greater than 250 mg/dl), surgery should be postponed by a few hours to obtain good glycemic control.

Severe anemia must be corrected before the patient undergoes surgery. Surgical blood loss may further worsen the pre-existing anemia. Severe anemia increases the risk of postoperative mortality. In patients with underlying cardiovascular disease, the risk of post-operative death significantly increases when preoperative hemoglobin is 10 g/dL or less. The physician should be alerted, so the cause of anemia is investigated, and transfusions are given as needed. In patients with no symptoms from anemia and no history of ischemic heart disease, hemoglobin above 7gm% is considered reasonable to undergo surgery. Those patients who are symptomatic from their anemia should be transfused as needed.

Choice A is incorrect. While many medications should be held before surgery, anti-convulsant such as carbamazepine should not be withheld. Post-operative electrolyte imbalances such as hypomagnesemia can increase the seizure potential in a patient with epilepsy. Anti-convulsant must never be withheld peri-operatively. If the patient ends up having a seizure intra-operatively or post-operatively, surgical outcomes may worsen.

Choice D is incorrect. Insomnia is not an absolute contraindication to performing surgery. Good sleep may help promote wound healing, and therefore, measures to improve sleep can be deployed after surgery.

Choice E is incorrect. While the nurse should inform the doctor regarding the prior history of the patient’s difficulty being anesthetized, this by itself does not increase the risk of surgical complications.

NCSBN client need
Topic: Reduction of Risk Potential: Potential for Complications for Surgical Procedures and Health Alterations.
Reference:
Lewis S, Dirksen S, Heitkemper M, Bucher L, Harding M. Medical-Surgical Nursing.

Question 13

The nurse is caring for an elderly patient who has become comatose. The patient’s living will specify that no life-extending procedures are to be done. However, the patient’s adult children are troubled and strongly objecting to this. How would the nurse effectively advocate for the patient in this situation?

A. Remind colleagues about the contents of the patient’s advance directives.

B. Document the wishes of the patient’s adult children.

C. Plan to respond slowly or incompletely should the patient experience cardiac arrest.

D. Develop a plan of care based on the preferences of the patient’s children.

Answer 13

Explanation

The correct answer is A. The living will is a legal document expressing the patient’s preferences regarding life-extending medical procedures. It is the nurse’s responsibility to support the patient’s right to autonomy and for self-determination, as shown in that document. One strategy to do so is to communicate the patient’s wishes to the health care team involved with the patient.

Choice B is incorrect. While documentation of the family’s objections and wishes may be done, it should not be considered to supersede the patient’s preferences, as stated in the living will.

Choice C is incorrect. Performing a “slow code,” responding slowly or incompletely to a cardiac arrest, is considered unethical, representing a violation of the patient’s trust and right to autonomy and self-determination.

Choice D is incorrect. Again, this option is a violation of the patient’s trust and the right to autonomy and self-determination.

Blooms Taxonomy - Analyzing
Reference:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8thEdition. Elsevier Mosby St Louis 2013.

Question 14

Which of the following are components of the definition of critical thinking? Select all that apply.

A. Reasoned thinking

B. Openness to alternatives

C. Adherence to established guidelines

D. Ability to reflect

E. Loyalty to traditional approaches

F. Desire to seek truth

Answer 14

Explanation

The correct answers are A, B, D and F. Critical thinking is a combination of reasoned thought, openness to alternatives, and ability to reflect, and a desire to seek the truth.

There are many definitions of critical thinking. It is a complex concept, and people think about it in different ways. Any situation that requires critical thinking is likely to have more than one “right” answer. You do not need critical thinking to add 2 + 2 and come up with the solution. However, you do need critical thinking to problem-solve essential decisions. A crucial aspect of critical thinking is the process of identifying and checking your assumption. This is also a necessary part of the research process. Critical thinking is a combination of reasoned thought, openness to alternatives, and ability to reflect, and a desire to seek the truth.

Choices C and E are incorrect.

o C- Adhering to established guidelines does not require critical thinking.

o E- Loyalty to traditional approaches does not demonstrate critical thinking and could actually hinder it.
NCSBN Client Need
Topic: Safe & Effective Care Environment; Subtopic: Management of Care
Reference:
Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith); Chapter02: Critical Thinking and Nursing Process; Lesson: What Is Critical Thinking?

Question 15

The nurse is about to lift a 350-pound patient using an electric lift from the bed and transfer him to a stretcher. What should be the priority nursing action?

A. Call for assistance from two staff members.

B. Make sure the client is correctly positioned in the lift prior to lifting.

C. Slowly lift the client off the bed.

D. Make sure the stretcher is locked.

Answer 15

Explanation

Choice B is correct. The safety of the client should take priority. The nurse must ensure that the client is safely secured and adequately attached to the lift. Incorrect positioning of the client in the lift’s sleeves might put the client at risk for falls.

Choice A is incorrect. The lift can be done by two persons, the nurse and one other staff; there is no need to call for two staff members. Moreover, the priority action is to ensure safety by securing the patient to the lift and ensuring proper positioning.

Choices C and D are incorrect. The nurse should ensure that the stretcher is locked and also slowly lift the client. However, the priority action is first to make sure the client is correctly positioned.
Reference
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevie

Question 16

What is the most appropriate nursing response when a Muslim patient requests that a basin of water on her bedside table not be emptied?

A. Tell him that the water is a health hazard

B. Talk with him about why he should not have it there

C. Empty it because it could spill and wet the bed

D. Support and accommodate his preference

Answer 16

Explanation

Choice D is correct. A devout Muslim patient may request to turn his bed to face Mecca, change his hospital gown, and place a basin of water near his bed for ritualistic handwashing before praying.

A, B, and C are incorrect. The health risks associated with having the basin of water on his bedside table are minimal compared with the benefit of supporting his spiritual needs.

NCSBN Client Need
Topic: Psychosocial Integrity

Resource:Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer);Lesson:Cultural Health Beliefs and Practices;Chapter10: Cultural Assessment

Question 17

The nurse and the LPN are working a busy shift at the pediatric ward. The nurse, to provide efficiency in the ward, should delegate which task to the LPN?

A. Administration of a medication in syrup form to an infant with a cleft palate

B. Providing discharge instructions to the mother of a child with epiglottitis

C. Changing of a colostomy bag to a toddler with anal atresia

D. Assess a child’s developmental level

Answer 17

Explanation

Choice C is correct. The LPN can perform a colostomy change. This is a routine nursing procedure that the LPN can perform adequately.

An LPN ( Licensed practical nurse’s) scope of practice includes providing ostomy care, monitoring the findings of Registered Nurse, reinforcing patient education, administration of most medications in stable patients, caring for ostomy sites/tubes; enteral feeding and checking for feeding tube patency.

An LPN may not perform an initial assessment: Initial assessments are to be performed by a Registered Nurse (RN). The first assessment is to be used to determine a patient’s baseline and develop an initial nursing plan of care. Once the first assessment has been completed, and the nursing plan of attention has been developed, the LPN may assist the RN in the nursing process. The LPN is to communicate any change of a patient’s status to the RN.

Choice A is incorrect. The LPN cannot administer medications in this case of a child with a cleft palate. This is because a child’s cleft palate poses a risk for aspiration to the infant. This needs the expertise and assessment of the registered nurse.

Choice B is incorrect. The LPN cannot provide discharge instructions.

Choice D is incorrect. Assessment of a child’s developmental level needs the skills and expertise of the nurse.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 18

As the charge nurse on 3 East, you have assigned a nursing assistant to transfer a client from the bed to the chair using a mechanical lift, which is something that is within the scope of practice and in the job description for nursing assistants. When the nursing assistant sees the written assignment, the nursing assistant says, “I don’t know how to use our mechanical lift.”

How should you respond to this nursing assistant?

A. “It is your responsibility to be able to use it. You have been taught about its proper and safe use and it is part of your job description.”

B. “I have looked at your competency checklist and you were deemed competent to use mechanical lifts during your orientation.”

C. “Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift.”

D. “Oh, that is okay. I will assign the transfer of this client using a mechanical lift to another nursing assistant.”

Answer 18

Explanation

The Correct Answer is C.The nurse should respond to the nursing assistant by saying, “Thank you for letting me know. I will work with you as we transfer the client safely and properly with the mechanical lift.” This statement allows the nurse to reeducate the nursing assistant about the use of a mechanical lift and determine the nursing assistant’s ability and competency to use it.

Choice A is incorrect. The nurse would not respond with a statement such as, “It is your responsibility to be able to use it. You have been taught about its proper and safe use, and it is part of your job description.” This statement does not address the underlying learning need of the nursing assistant.

Choice B is incorrect. The nurse would not respond with a statement such as, “I have looked at your competency checklist, and you were deemed competent to use mechanical lifts during your orientation.” This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift.

Choice D is incorrect. The nurse would not respond with a statement such as, “Oh, that is okay; I will assign the transfer of this client using a mechanical lift to another nursing assistant.” This statement does not address the underlying learning need for retraining and education about the use of a mechanical lift.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 19

Arrange Maslow’s hierarchy of needs from the highest to the least priority.
Physiological needs
Safety
Love and belonging
Esteem
Self-actualization

Answer 19

Correct Answer is:
Physiological needs
Safety
Love and belonging
Esteem
Self-actualization

Explanation

In needs theories, human needs are ranked on an ascending scale according to how essential the requirements are for survival. One of the most renowned needs theorists, Abraham Maslow, lists human necessities on five levels.

The correct order from highest to least priority is :

Physiological needs- Needs such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance are crucial for survival.
Safety- The need for security has both physical and psychological aspects. The person needs to feel safe, both in the physical environment and in relationships.
Love and belonging- The third level of needs includes giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging.
Esteem- The fourth level of needs encompasses esteem for oneself (dignity, achievement, mastery, freedom) and the need to be accepted and valued by others (e.g., social status, prestige). Esteem needs constitute one of the key stages in achieving contentment or self-actualization.
Self-actualization- When the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop one’s maximum potential, and realize one’s abilities and qualities. This is a higher-level need on Maslow's pyramid so, a lower priority.

Question 20

Which of the following sacred symbols is most similar to rosary beads that are a sacred symbol for Catholics?

A. A sari for a female Hindu believer

B. A sari for a female Buddhist believer

C. A mala for a practicing Muslim

D. A mala for a practicing Hindu

Answer 20

Explanation

Choice D is correct. A mala for a practicing Hindu is the most like rosary beads that are a sacred symbol for Catholics. Like rosary beads, a mala is a holy object that is carried by members of the Hindu religion. Many of the world’s religions have sacred objects.

Choice A is incorrect. A sari for a female Hindu believer is a piece of clothing that is worn and not carried as rosary beads, a sacred object that is carried by Catholics.

Choice B is incorrect. A sari for a female Hindu, rather than a Buddhist, is a piece of clothing that is worn and not carried as rosary beads, a sacred object that is carried by Catholics.

Choice C is incorrect. Although Muslims use sacred beads, Islamic prayer beads are called Misbaha or Tasbih, not Mala. Buddhists and Hindus use the “Japa Mala”.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 21

During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP) working with her. After charging, which of the following is the nurse’s primary responsibility?

A. Document the completion of the task

B. Make a list of tasks not yet completed to pass on to the next shift

C. Observe the UAP for the duration of the task

D. Follow-up with the UAP to ensure completion of the task, evaluating the outcome.

Answer 21

Explanation

D is correct. The nurse should follow-up with the UAP to ensure completion of the task, evaluating the outcome. The ultimate responsibility for any job will always remain with the person who delegated it. Therefore, after delegating a task, the nurse’s primary responsibility will be to follow up with the UAP.

A is incorrect. The nurse’s primary responsibility after delegating a task will be to follow up with the UAP. The nurse cannot document the completion of the job until the follow-up has been performed.

B is incorrect. It is unnecessary to make a list of tasks not yet completed to pass on to the next shift. The nurse’s primary responsibility after delegating a job will be to follow up with the UAP.

C is incorrect. If delegating correctly, the nurse must delegate a task within the scope of practice of the UAP and therefore does not need to observe the UAP for the duration of the job. The nurse’s primary responsibility after delegating a task will be to follow up with the UAP.

NCSBN Client Need:

Topic: Effective, safe care environment; Subtopic: Infection control and safety

Subject: Fundamentals; Lesson: Prioritization, delegation, and leadership

Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.

Question 22

You are in a client’s room and are suddenly interrupted with a fire alarm as you are documenting client care in the client’s electronic medical record. What should you do?

A. Follow the RACE procedure to address this internal disaster.

B. Rescue all clients and visitors from immediate danger.

C. Log off the computer.

D. Determine whether or not it is a fire drill.

Answer 22

Explanation

Correct Answer is C.You must immediately and rapidly log off the computer to maintain information security and clients’ medical records and information privacy. You would then shortly follow the RACE procedure. It would only take a few seconds to log off the computer. It is essential to protect client privacy under the HealthInsurance Portability and Accountability Act (HIPAA). Patients may take advantage of an open computer terminal to look at their records, leading to a HIPAA violation if they access another patient’s health information. Although most computers are programmed to automatically log off after a specific time, this should not be relied upon as a backup. It is important to log off when the RN leaves the area, even if she is going for a minute or two.

Some common HIPAA violations that nurses make:

You forget to log out of the computer terminal.
They were throwing out handwritten notes that have protected patient information in an insecure fashion.
We were discussing patient cases with uninvolved coworkers.
I am speaking with unauthorized patient's family members or friends.
Taking selfies with patients and posting on social media
We are using unsecured channels outside medical software to communicate with the care team (e.g., texting patient information via. personal cell text message).
Failure to report HIPAA violations promptly.
Failure to take required HIPAA training.

Choice A is incorrect. Following the RACE procedure for this internal disaster is not the first step here. You can immediately log off and then move to follow the RACE procedure.

Choice B is incorrect. You would not immediately rescue all clients and others because something else must be done first.

Choice D is incorrect. You would not determine whether or not this is a fire drill because something else must be done first. Additionally, you must respond to all fire alarms as if it is an actual fire.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 23

The trauma team is preparing to intubate a patient who sustained severe facial trauma following a motor vehicle accident. The doctor states, “I need 40 mg of succinylcholine and 80 mg of etomidate. Let us go ahead and hang two bags of warm normal saline and give mannitol too.” Which drug does the nurse administer first?

A. Succinylcholine

B. Etomidate

C. 0.9% NaCl

D. Mannitol

Answer 23

Explanation

Choice B is correct. Etomidate should be administered first. The patient’s airway is the most critical assessment to focus on, primarily in cases of facial trauma. Facial trauma may cause airway obstruction due to swelling. Additionally, accompanying traumatic brain injury may predispose the client to aspiration. Therefore, the airway needs to be secured first. Rapid sequence intubation (RSI) rather than routine tracheal intubation is preferred in this situation. There is impending airway obstruction, and there is not enough time to adequately prepare a patient for regular intubation. The goal of RSI to sedate and paralyze the client in order to allow for intubation without having to apply artificial breaths via a bag valve mask (BVM).

Etomidate and Succinylcholine are the two drugs that are given before rapid-sequence intubation (RSI). Because of its sedative effects, Etomidate should be administered first. An ideal sedative should have a rapid onset of action, short duration of work, and non-significant hemodynamic effects. Etomidate fits those criteria.

Succinylcholine is a paralytic and should be administered after the Etomidate. It is important to remember that the client needs to be sedated before he is paralyzed. Therefore, a paralytic drug should never be administered first.

Choice A is incorrect. Succinylcholine should only be administered after giving a sedative agent during RSI.

Choice C is incorrect. Fluids may need to be initiated, but intubation should be performed first due to facial trauma. The airway needs to be secured before doing anything else.

Choice D is incorrect. Mannitol needs to be given eventually due to head trauma. Head trauma may cause cerebral edema and increase intracranial pressure. Mannitol does not cross the blood-brain barrier and is an osmotic diuretic that decreases the swelling in the brain. The patient, however, needs to be intubated first and then mannitol can be administered.
NCSBN Client Need
Topic: Management of Care; Sub-topic: Establishing Priorities

Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013, Lesson: Emergencies, Disaster nursing.

Question 24

The nurse is having her shift in the Emergency Department and is assigned to triage patients coming in for treatment. Which patient should the nurse attend to first?

A. a client complaining muscle pains, and headache

B. a client complaining of a sore foot after twisting his ankle in a game of basketball

C. a client who is manifesting shortness of breath, wheezing and cyanosis followed by a bee sting

D. a client with a splinted fractured humerus being escorted by paramedics

Answer 24

Explanation

C is correct. Upon initial presentation, the client is undergoing an anaphylactic shock. Clients with severe respiratory distress are classified as emergent and should be given priority.

A is incorrect. Triaging is a system of client evaluation to establish priorities and assign appropriate treatment and personnel. A patient complaining of muscle aches and a headache should fall under non-urgent priority.

B is incorrect. Client conditions such as sprains, minor lacerations, and cold symptoms are also classified as non-urgent.

D is incorrect. Client conditions like fractures are classified as urgent and should be given treatment as soon as possible. However, new cases always supersede that of critical situations.

Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier

Question 25

The nurse is caring for a client with the tracing on the electrocardiogram shown in the Exhibit. The nurse should perform which priority action?

EXHIBIT — SINUS BRADYCARDIA

A. Discontinue the prescribed diltiazem infusion.

B. Notify the primary healthcare physician (PHCP).

C. Assess the client’s oxygen saturation and respiratory rate (RR).

D. Prepare a prescription of intravenous (IV) atropine.

Answer 25

Explanation

The tracing shows sinus bradycardia (SB).

The priority action would be to discontinue the diltiazem as it is a calcium channel blocker that lowers heart rate.

The physician should be notified, and oxygen saturation should be assessed. However, the priority action is to discontinue the offending agent.
NCSBN Client Need
Topic: Physiological adaptation; Sub-Topic: Medical Emergencies

Question 26

When making patient care assignments, the nurse recognizes that the following tasks are within the scope of practice for nursing assistive personnel [NAP], with which exception?

A. Providing catheter care.

B. Performing range of motion exercises.

C. Changing the colostomy skin barrier.

D. Encouraging the use of self-help devices.

Answer 26

Explanation

Correct Answer is C. The NAP scope of practice allows the NAP to empty ostomy bags or change bags that do not adhere to the skin; the NAP could apply a new pack to a two-piece system, but not the adhesive skin barrier component.

Choices A, B, and D are incorrect. Providing catheter care, performing a range of motion exercises, and encouraging the patient to use self-help devices are within the NAP scope of practice.

Bloom’s Taxonomy: Analyzing
Reference:
McMullen, Tara L. et al. Certified Nurse Aide Scope of Practice: State-by-State Differences in Allowable Delegated Activities Journal of the American Medical Directors Association, 2015; 16(1) 20 - 24

Question 27

During nursing school, you have been taught to be open and frank with all clients, even when information may be upsetting and distressing to the client. By doing this, you are following the ethical principle of:

A. Beneficence.

B. Veracity.

C. Nonmalficence.

D. Fidelity.

Answer 27

Explanation

The correct answer is B. You follow the ethical principle of integrity when you are open, frank, and truthful with all clients, even when information may be upsetting and distressing to the client.

Choice A is incorrect. You are not following the ethical principle of beneficence when you are open, frank, and truthful with all of your clients, even when information may be upsetting and distressing to the client. Beneficence is defined as “doing good” for our patients and not being frank and open with clients’ communication.

Choice C is incorrect. You are not following the ethical principle of nonmaleficence when you are open, frank, and truthful with all of your clients, even when information may be upsetting and distressing to the client. Nonmaleficence is defined as “doing no harm” to our patients.

Choice D is incorrect. You are not following the ethical principle of fidelity when you are open, frank, and truthful with all of your clients, even when information may be upsetting and distressing to the client. Fidelity is defined as being faithful to our promises to our patients.

Reference: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 28

A client who completes an informed consent is asserting and using their basic right to:

A. Beneficence.

B. Nonmaleficence.

C. Self-determination.

D. Have choices.

Answer 28

Explanation

The correct answer is C. A client who completes an informed consent is asserting and using their fundamental right to self-determination. Self-determination is defined as the intrinsic right of all people, including healthcare consumers, to make their own autonomous decisions about accepting or rejecting care or treatments, as is done with informed consent.

Choice A is incorrect. Beneficence is an ethical principle that states that we should “do good” for the client, and it is not the basis of informed consent.

Choice B is incorrect. Nonmaleficence is an ethical principle that states that we should “no harm” to the client, and it is not the basis of informed consent.

Choice D is incorrect. Although the client makes choices with informed consent, making choices is not the basis of informed consent; making choices among alternatives of treatments is supported.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 29

A registered nurse has encountered an ethical dilemma regarding euthanasia in the medical unit earlier in the day. The nurse verbalizes to the manager that she is concerned about what she witnessed. Does the manager suggest which resource for the RN to utilize?

A. Rights for the Mentally Ill

B. Client’s Bill of Rights

C. Code of Ethics

D. Nurse Practice Acts (NPA)

Answer 29

Explanation

Choice C is correct. The Code of Ethics for nurses provides ethical guidelines regarding nursing practice.

Choice A is incorrect. The Rights for the Mentally Ill provides people with mental illness the civil liberties that are due to them.

Choice B is incorrect. The Patient’s Bill of Rights outlines the rights that are due to them when admitted and seeking health care.

Choice D is incorrect. Nurse practice acts describe the scope of nursing practice. It directs the philosophy and standards of nursing.
Reference
Potter, PA, Perry. AG, Stockert, PA, Hall, AM. Fundamentals of Nursing, 8th ed. St. Louis, MO: Elsevier Mosby;2013

Question 30

The nurse and the Licensed Practical Nurse (LPN) are assigned to a busy medical unit. Which of the following tasks would be appropriate for an LPN to take? Select all that apply.

A. Reinforcing newborn care education to a 24-year-old first-time mother.

B. Adjustment of a 68-year-old stable patient’s cervical traction as ordered by the provider.

C. Obtaining a fecal occult blood sample from a 16-year-old patient with ulcerative colitis.

D. An assessment of a 36-year-old man newly admitted for chest pain.

Answer 30

Explanation

Choices A, B, and C are correct. Initial teaching does not fall within the scope of practice of an LPN. A registered nurse always performs initial instruction. However, LPNs can “reinforce” education (Choice A) to a client. Generally, the tasks that require “critical thinking” should not be delegated to an LPN. Tasks such as obtaining stool samples for occult blood (Choice B) and following health care provider’s orders to adjust cervical traction (Choice C) are all within the scope of practice of an LPN and do not require critical thinking process. LPNs can also apply and remove the cervical collar on stable spinal patients.

If the cervical traction is being applied for neck fractures, RNs or LPNs should not remove or add the traction weight since such patients have spinal instability. For an unstable client in traction, an RN should assess the neurovascular status, and document as ordered. Assessment or caring for unstable clients is not within the scope of LPN practice. However, cervical traction may also be applied for other reasons such as osteoarthritis, etc. In a client with stable clinical status and predictable outcomes, adjusting cervical traction as ordered by the provider falls within the scope of LPN practice. Choice B does not mention any unstable findings that fall outside the scope of an LPN.

For any question regarding delegation to LPNs, please make sure you determine the complexity and predictability of the client.

A Registered Nurse (RN) is responsible for determining the level of complexity and predictability of a client’s presentation. The RN documents this in an established plan of care. The LPNs accountability for the outcomes of care and independence of practice depends mostly on the predictability and complexity of the client presentation. Please note that the scope of practice is based on decisions around a task, not the job itself.

Predictability involves assessment of how effectively a health condition is managed, the changes likely to occur, and whether the type and timing of change can be predicted (College of Nurses of Ontario,1997, p.6). Complex or unstable situations are those where the patient’s status is fluctuating with unexpected responses resulting in an elaborate plan of care.

In cases where there is a high degree of complexity and a low degree of predictability, RNs are solely accountable for outcomes of care (“unstable” situations). In these cases, custody is determined by frequent assessments. The LPN practice in these cases is DIRECTED by the RN in that decisions of care are made by the RN only. Interventions change often, and patients’ responses to intrusions may be unexpected or high risk.
In acute cases where there are equal degrees of complexity and predictability, RNs and LPNs share accountability for the outcomes of care. LPN practice is COLLABORATIVE with the RN in that decisions of responsibility are made by the RN and LPN together.
In stable situations where there is a low degree of complexity and a high degree of predictability, the plan of care can be readily established. It can be managed with interventions that have predictable outcomes. Here, LPNs are solely accountable for the results of care. LPN practice is INDEPENDENT of the RN. The LPN is responsible for determining that the skills are appropriate for the patient.

Planning is not within the scope of an LPN. LPNs cannot formulate a care plan but may collaborate with an RN’s care plan.

In short, one may remember a popular mnemonic “DO NOT DELEGATE WHAT YOU EAT (LPNs cannot Evaluate, Assess, Teach).”

Choice D is incorrect. LPNs can perform focused assessments. However, initial and comprehensive assessments should always be performed by a registered nurse or an attending physician. The client with chest pain may involve a high degree of complexity and a low degree of predictability. Such assessment and planning require the critical thinking process.

Here is a 5-minute refresher video on the LPN Scope of Practice:

https://www.youtube.com/watch?v=EkYe7rSsJkk

Question 31

While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient’s son is silently holding her hand and praying. Which of the following should be the nurse’s initial action?

A. Continue preparing for the procedure in the room.

B. Notify the chaplain.

C. Leave the room quietly and come back after 15 minutes to change the client’s dressing.

D. Ask the son if he wants the nurse to join in prayer.

Answer 31

Explanation

Choice C is correct. The nurse should respect the client and her son in their moment of prayer and should not impose on them. The nurse’s best action is to leave the room and come back when they are finished praying.
Choices A, B, and D are incorrect.
It is inappropriate for the nurse to continue preparing for the procedure (Choice A). The nurse should respect the client and her son’s need for privacy during the prayer. The most appropriate action of the nurse is to leave the room momentarily. Unless requested by the client, the nurse should not inform the chaplain ( Choice B) or any other person. Asking the son if she can be allowed to join the prayer ( Choice D) is inappropriate. The nurse should respect their right to privacy and should not impose on the client.
Reference
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care,

Question 32

What tool, or graphic display, that is shown in the Exhibit can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with systems theory?

A. Histogram

B. A Scatter-gram

C. Genogram

D. Ecomap

Answer 32

Explanation

The Correct Answer is D.The tool, or graphic display that is shown above is an ecomap or an ecogram. Ecomaps can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with systems theory Ecomaps show the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.

Histograms and scattergrams show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.

Genograms show medical information and risk factors in a realistic manner and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.

Choice A is incorrect. Histograms show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact the individual, family, and community.

Choice B is incorrect. Scatter grams show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.

Choice C is incorrect. Genograms show medical information and risk factors in a realistic manner and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.

NCSBN Client Need: Topic: Psychosocial Integrity; Sub-Topic: Family Dynamics.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 33

Which of the following is an improper technique for correcting written documentation? Select All That Apply.

A. Draw a line through the error, write the date, time, and reason for the error, and add your initials

B. Use correction tape and write over the error so there is no confusion

C. Write over the error in darker ink

D. Completely black out the error with a black marker

Answer 33

Explanation

Choices B, C, and D are correct. All of these practices are inappropriate methods of correcting written documentation. Using a tape, writing over the sentence using a black ink, and blacking out using black marker are attempts to conceal the original documentation and may be considered illegal in a court. In a court of law, the court needs to see the underlying data that were corrected. No effort should be made to obliterate the error.

Choice A is incorrect. It is not illegal for medical professionals to make the necessary updates to records, as long as they follow proper methods and do not obscure information. Choice A, in fact, is the correct technique for correcting the written documentation.

NCSBN Client Need I Topic: Health Promotion and Maintenance

Reference: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer); Chapter 4: Documentation and Interprofessional Communication; Lesson: Accuracy and Completeness

Question 34

You are caring for a 76-year-old male client who is adversely affected by ataxia secondary to a cerebrovascular accident. Which member of the interdisciplinary team would you most likely collaborate with to address this deficit?

A. An occupational therapist.

B. A speech therapist.

C. A dietician.

D. A physiatrist.

Answer 34

Explanation

The correct answer is D. You would most likely collaborate with a physiatrist to address this ataxia secondary to a cerebrovascular accident. A physiatrist is a medical doctor with specialized training and education in rehabilitation and restorative care processes.

Choice A is incorrect. You would not most likely collaborate with an occupational therapist because occupational therapists are most often involved in the rehabilitation and restorative care of clients who are adversely affected with limitations in terms of their activities of daily living and no ataxia.

Choice B is incorrect. You would not most likely collaborate with a speech and language therapist because speech and language therapists are most often involved in the rehabilitation and restorative care of clients who are adversely affected by communication and swallowing deficits and not ataxia.

Choice C is incorrect. You would not most likely collaborate with a dietician because dieticians are most often involved in the care of clients who are adversely affected by malnutrition and swallowing deficits and not ataxia.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 35

Which process is most often used by performance improvement teams to find the most basic causes of process failures?

A. Root cause analysis.

B. Nominal group process.

C. Determining who failed.

D. Negotiation.

Answer 35

Explanation

Correct Answer is A. Root cause analysis process is most often used by performance improvement teams to find the most basic causes of process failures. Root cause analysis is done in a blame-free environment to dig down to the most fundamental reasons why a failed process is not fail-proof.

Choice B is incorrect. The nominal group process is rarely, if ever, used by performance improvement teams.

Choice C is incorrect. Determining who failed is not an acceptable process for performance improvement teams. Performance improvement activities are conducted in a blame-free environment.

Choice D is incorrect. Although negotiation is an effective and appropriate group process, it is not used to find the most basic causes of process failures.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 36

The nurse and the LPN are caring for a client who is in four-point restraints due to combative behavior.
Which of the following interventions may the nurse assign to the LPN/ LVN?

A. Assess the patient’s skin integrity around the restraints hourly.

B. Ensure that the physician has renewed the order for restraints, as should be done every 12 hours.

C. Release the leg restraints to give the patient a break and see if his combative behavior has improved.

D. Have the attending physician discontinue the restraints and give the patient a chance to behave better.

Answer 36

Explanation

The correct answer is A. While on restraints, combative patients should be assessed hourly and non-combative patients every two hours to ensure that skin breakdown around the controls has not occurred. LPN/LVN is not allowed to do an initial or comprehensive assessment. However, focused assessment such as the one in Choice A falls under the scope of LPN/ LVN.

Choices B, C, and D are not correct. None of these answer options is the LPN/LVNs responsibility.

NCSBN Client Need

Topic: Safe and Effective Care Environment

Subtopic: Safety and Infection Control

Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn)

Chapter 26: Safety, Security, and Emergency Preparedness

Lesson: Using Restraints in the Healthcare Facility

Question 37

A patient recovering from myocardial infarction is presenting with Heart rate 110 beats per minute, Blood Pressure 86/58 mmHG, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority?

A. Administer medications to increase stroke volume.

B. Provide analgesics.

C. Obtain STAT Electrocardiogram and troponins

D. Administer fluid replacement to increase blood pressure.

Answer 37

Explanation

Choice A is correct. Based on the assessment information, the nurse can determine the patient is experiencing cardiogenic shock secondary to myocardial infarction. Since cardiogenic trauma occurs as a result of the heart not pumping effectively, the highest priority is to increase cardiac output to ensure adequate tissue perfusion.

Cardiac Output = Stroke volume x Heart Rate.

Medications that improve stroke volume will improve cardiac output in cardiogenic shock. The following agents may be used in the pharmacological management of cardiogenic shock.

Inotropes: Positive Inotropes strengthen the heart contractility (increase stroke volume). Dobutamine has more beta-adrenergic action than alpha activity. It causes peripheral vasodilation while increasing contractility. But in higher doses, it may increase heart rate and exacerbate myocardial ischemia.
Vasopressors: In severe shock, Vasopressors (Dopamine, Norepinephrine) maintain blood pressure but decrease blood flow to organs. They increase afterload and reduce cardiac output. However, they may be needed initially to provide hemodynamic support. Dopamine increases myocardial contractility and maintains blood pressure. If Dopamine fails to support blood pressure, norepinephrine is added.
Vasodilators: Vasodilators (Nitroglycerin) decrease venous return (preload) to the heart and decrease peripheral resistance (afterload). Although vasodilators may drop blood pressure, they sustain cardiac output and help achieve hemodynamic stability when combined with vasopressor support in cardiogenic shock.
Supplemental oxygen may also be necessary to increase tissue oxygenation.

Choice B is incorrect. There is no assessment information in the question that points to chest pain. If a patient in cardiogenic shock is showing signs or complaining of pain, this action would be appropriate, but not the highest priority.

Choice C is incorrect. The patient recently experienced MI, so they should already be on a telemetry monitor. ECG will likely be abnormal, and troponins may still be elevated. This action may be appropriate but will not change the immediate treatment of shock, so it would not be the highest priority.

Choice D is incorrect. Fluid replacement is not the correct immediate action because the patient is showing signs of pulmonary edema (crackles, shortness of breath, jugular vein distention). Cardiac output needs to be improved before considering the additional fluid volume. This action might be appropriate if the patient was in hypovolemic shock, not cardiogenic.

NCSBN Client Need
Topic: Establishing priorities, illness management, medical emergencies, pathophysiology,

Reference: (Jones & Fix, 2015, p. 234-236), (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1733), (Huether & McCance, 2008, p. 659)

Question 38

While preparing to administer a newly ordered medication, the nurse notices that the dosage prescribed is higher than the usual recommended dosage. Despite trying multiple times, the nurse is unable to locate the ordering physician. The medication is due to be administered. Which action should the nurse undertake first?

A. Contact the unit’s nursing supervisor

B. Administer the dose as prescribed since the nurse is protected by a written order

C. Hold the medication until the physician can be contacted and the order is clarified

D. Administer what the nurse knows as the recommended dose until the physician can be located

Answer 38

Explanation

Choice A is correct. The nurse must contact the nursing supervisor. If the physician writes a prescription that is questionable or requires clarification, the nurse’s responsibility is to contact the physician. But a resolution regarding the order may not be immediately reached because the physician may not be located or the physician may insists on keeping the medicine as it was written. In such cases, the nurse should contact the nurse manager or nursing supervisor for further clarification. The nursing supervisor can determine the appropriate steps that should be taken.

Choice B, C, and D are incorrect. Once the nurse is aware that the prescription is inappropriate, the nurse should never proceed to carry out the prescription as it is ( Choice B). Nurses have legal and ethical obligations to protect the client. Simply holding the medication until physician can be contacted ( Choice C) is inappropriate since the medication is due to be administered. The nurse should inform the supervisor so appropriate steps can be determined. Administering what the nurse knows ( Choice D) and taking independent treatment decisions regarding the medication dosage is an inappropriate nursing practice.

Question 39

You are educating a new nurse regarding Sentinel Events. Which of the following are examples of Sentinel events? Select all that apply.

A. An untimely assessment of the client.

B. An incomplete assessment of the client.

C. A client falls from the chair to the floor and sustains a humerus fracture.

D. An incorrect client is almost sent to the operating room.

E. A client undergoes colectomy instead of appendectomy.

Answer 39

Explanation

Choice C and E are correct. A sentinel event is defined as an event that has reached the patient and caused harm ( death, permanent harm, or severe temporary harm). A sentinel event is unrelated to patient’s illness or underlying condition. Such events are called “sentinel” because they signal a need for immediate investigation and response. All sentinel events must be reviewed by the hospital and are subject to review by The Joint Commission. A sentinel event may occur due to medical errors like wrong-site, wrong-procedure, wrong patient surgery. Please note that the terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.

Choice C (“client falls from the chair to the floor and sustained humerus fracture”) is an actual event that has occurred and caused harm. This event ( fall causing injury) is not a medical error, but constitutes a sentinel event. Choice E ( a client undergoing colectomy instead of appendectomy) is a sentinel event due to a medical error. Other examples of sentinel events include : patient committing suicide while receiving care in the hospital or within 72 hours of discharge, hemolytic transfusion reaction, unanticipated death of a full term infant, rape, assault, sexual abuse, invasive procedure on the wrong site/wrong person/ wrong procedure, discharge of infant to wrong family, any intrapartum maternal death, and so on.

Patient safety events occur commonly in health systems worldwide. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. Safety events can be categorized into sentinel events, adverse events, near misses, and no harm events. Sentinel events are just one category of patient safety events. Others include:

An adverse event: a patient safety event that resulted in harm to a patient. ( eg; an adverse event could include side effects to medications/ vaccines, medical procedures. They may or may not be from negligence. For example, a patient sustaining embolic stroke after a coronary angiography is an adverse event, but not due to medical negligence.)
A no-harm event is a patient safety event that reaches the patient but does not cause harm.
A close call (or a "near miss" or a "good catch") is a patient safety event that did not reach the patient.
A hazardous (or unsafe) condition(s) is a circumstance (other than a patient's own disease process or condition) that increases the probability of an adverse event.

Choice D is incorrect. The event ( when an incorrect client is almost sent to the operating room) did not occur here and did not cause patient harm. This event is referred to as “near-miss”, not a sentinel event. WHO defines “near-miss” as the one with the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is prevented According to the Institute of Medicine, a near miss is an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation.” An error caught before reaching the patient is another definition. It is also referred to as “close call or “potential adverse event.” Near misses also must be reported so root cause analysis can be completed. The root causes of near misses and adverse/sentinel events are similar. Detecting root causes of near misses, therefore, can help us to correct these causes and prevent future adverse events.

Choices A and B are incorrect. Although an untimely assessment of the client and an incomplete assessment of the client can be contributory factors that led to a sentinel event, these are considered deviations from a standard of care and not sentinel events.

References: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice

Question 40

A client with Addison’s disease was admitted with nausea and vomiting two days ago. His symptoms now resolved, and vital signs are stable. The client is receiving intravenous glucocorticoids. Which action by the nurse should receive priority?

A. Checking the client’s blood sugar level.

B. Measuring intake and output.

C. Checking the client’s sodium and potassium levels.

D. Taking daily weights.

Answer 40

Explanation

The correct answer is A. Intravenous glucocorticoids elevate the client’s blood sugar level and may sometimes require insulin to bring it back to normal. The nurse should prioritize checking the client’s blood sugar levels to monitor and prevent complications due to steroid-induced hyperglycemia.

Addison’s disease refers to primary adrenal insufficiency secondary to autoimmune etiology. These patients tend to have both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) deficiencies. Often, these patients are treated with replacement doses of glucocorticoids (hydrocortisone) and mineralocorticoids (fludrocortisone). While glucocorticoids may have acute side effects such as hyperglycemia, and weight-gain; mineralocorticoids may lead to side effects related to aldosterone excesses such as hypernatremia and hypokalemia.

Choice B is incorrect. The nurse should measure the intake and output of clients with nausea and vomiting to assess fluid status. However, since the client is taking IV glucocorticoids and his vital signs (blood pressure) are reported to be within normal limits, the nurse should make checking blood sugar levels a priority action over measuring intake and output.

Choice C is incorrect. The client is receiving IV glucocorticoids, which increases the risk of acute hyperglycemia. The client is not yet on mineralocorticoids. Should the client be getting mineralocorticoids, there will be an increased risk for the client to develop hypokalemia and hypernatremia. Nausea and vomiting can also cause electrolyte imbalances; however, the client admitted three days ago, and those symptoms have resolved.

Choice D is incorrect. Measuring daily weights may be indicated to monitor for fluid retention and weight gain on replacement steroids. However, hyperglycemia is a more acute side effect and must be prioritized.
NCSBN Client Need:
Topic: Management of care; Sub-Topic: Establishing Priorities.
Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 41

The primary objective of identification of similarities and differences among the cultural beliefs of the patients by the nurse is to:

A. Communicate with the family

B. Make sure the proper diet is ordered

C. Perform a spiritual consult

D. Avoid making assumptions

Answer 41

Explanation

Choice D is correct. Making assumptions or generalizations about a patient’s spiritual needs based on ethnic or religious affiliation is almost sure to be an oversimplification. The nurse should be able to identify similarities and differences among the cultural beliefs of the patients. Just because a patient belongs to certain culture or ethnicity, it is incorrect to generalize their spiritual needs.

Choices A, B, and C are incorrect. Ordering a specific diet as per the patient’s specific cultural or religious preference is certainly warranted. However, generalizations can not be made here either and knowing patient’s specific preference will help the nurse cater to patient’s dietary or spiritual needs. Communicating with the family and performing a spiritual consult should also be done at the patient’s request. While identification of cultural similarities and differences among the patients can help guide these processes, these are not the primary objectives. The primary objective is to avoid making assumptions.

NCSBN Client Need: Topic: Psychosocial Integrity

Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer); Chapter 10: Cultural Assessment; Lesson: Characteristics of Culture

Question 42

An example of a healthcare environment that provides tertiary prevention care and services is a(n):

A. Acute care facility.

B. Primary care outpatient clinic.

C. Outpatient surgical center

D. Physical rehabilitation center in the community.

Answer 42

Explanation

Correct Answer is D. An example of a healthcare environment that provides tertiary prevention care and services is a physical rehabilitation center in the community.

Choice A is incorrect. An acute care facility provides primary prevention care and services, not tertiary prevention care and services.

Choice B is incorrect. A primary care outpatient clinic provides primary prevention care and services, not tertiary prevention care and services.

Choice C is incorrect. An outpatient surgical center provides secondary prevention care and services, not tertiary prevention care and services.

References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.

Question 43

The nurse notes that the physician has entered a do not resuscitate [DNR] order. However, there is no advanced directive by the patient present on the patient’s chart. Which is the appropriate nursing action?

A. Notify the physician about the need for a living will to validate this order.

B. Verify that the physician consulted with the patient and/or family.

C. Accept the order as written, no other documentation is needed.

D. Notify the nurse supervisor and risk management about the DNR order.

Answer 43

Explanation

The correct answer is B. Documentation that the physician has consulted with the patient and family is required before a do not resuscitate order is entered on the patient’s chart.

Choice A is incorrect. It is not necessary to have a living will on the patient’s chart, but there must be documentation that the issue was discussed with the patient/family.

Choice C is incorrect. There must be documentation noting that the DNR order was discussed with the patient and family.

Choice D is incorrect. It is not necessary to notify the nursing supervisor and risk management about this order.

Bloom’s Taxonomy – Applying
Reference:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8thEdition. Elsevier Mosby St Louis 2013

Question 44

The nurse on a medical floor receives a report on four patients. Which patient should the nurse see first?

A. A client with pulmonary embolism on anticoagulation, dyspnea, and pCO2 of 30mmHg

B. A client with atrial fibrillation on Warfarin, history of prior rectal bleeding and an INR of 6.0

C. A client Congestive Heart Failure and Brain Natriuretic Peptide of 640 pg/mL

D. A client with Acute pancreatitis and serum calcium of 8.9 mg/dL

Answer 44

Explanation

Choice B is correct. While answering prioritization questions, it is essential to determine which findings are unexpected and which pose an immediate risk of complications to the client. The target International Normalized Ratio (INR) for atrial fibrillation is 2.0-3.0. A supra-therapeutic INR of 6.0 is too high for this patient and puts the patient at high risk for bleeding. Additionally, given his prior history of gastrointestinal bleeding, he is more prone to recurrent bleeding in the setting of coagulopathy. The nurse should hold warfarin, assess the patient for signs of bleeding and notify the physician of abnormal results to determine if vitamin K should be administered to counter the effects of warfarin.

Choice A is incorrect. The client has an established diagnosis of Pulmonary Embolism (PE) and is on therapeutic anticoagulation. Dyspnea and elevated D-dimer are expected results in patients with known PE. D-dimer reflects thrombin and plasmin activity and is usually positive in hospitalized patients with thrombotic events. Low pO2 (Hypoxia) and low pCO2 (Respiratory alkalosis) are expected findings in patients with PE. Normal PCO2 is 35-45 mmHg, so 30 mmHg is small but not critical (<20 mmHg).

Choice C is incorrect. Brain Natriuretic Peptide is a marker for Congestive Heart Failure (CHF) because it correlates with left ventricular pressure. High Left ventricular pressures and high BNP levels are expected findings in patients with heart failure. A BNP more top than 100 pg/mL is abnormal. The client has an established diagnosis of CHF, and a report of BNP at 640 pg/mL does not require immediate action.

Choice D is incorrect. Acute pancreatitis can cause decreased calcium levels (hypocalcemia). Severe hypocalcemia may be seen in acute pancreatitis and can present with neurological as well as cardiovascular manifestations. However, since the normal range for serum calcium level is 8.6-10.2 mg/dL, this patient’s result of 8.9 mg/dL is within normal range and would not warrant any intervention.

NCSBN Client Need:
Subject: Leadership/management; Lesson: Prioritization

Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 578-579)

Question 45

The client’s nephew walks up to the nurse’s station and asks if he can see his uncle’s file. The nephew states, “It’s okay, I’m a nurse as well. I just want to take a quick look and see how my uncle is doing.” What is the nurse’s most appropriate response?

A. “You can take a look for only 5 minutes.”

B. “Let me get an approval from the attending physician.”

C. “I will need permission from your uncle first.”

D. “Non-hospital employees can not view the patient’s file.”

Answer 45

Explanation

The correct answer is C. According to the Health Insurance Portability and Accountability Act (HIPAA), the relative must first obtain consent from the client to view his file.

Choice A is incorrect. According to the Health Insurance Portability and Accountability Act, the relative must first obtain consent from the client to view his file. In the absence of the client’s permission, allowing the nephew to view the data even for 5 minutes is not legal.

Choice B is incorrect. The physician is not the one that decides who can view the client’s file. The client’s consent is necessary under HIPAA provisions.

Choice D is incorrect. Non-employees can view the client’s file once the client has given consent for them to see his data.
Reference
Potter, PA, Perry. AG, Stockert, PA, Hall, AM. Fundamentals of Nursing, 8th ed. St. Louis, MO: Elsevier Mosby;2013

Question 46

The client is admitted to the surgical ward after being treated initially in the ER for a femur fracture due to a motor vehicle accident. The client is being interviewed by the nurse for his surgery whenhe suddenlyreports a sharp pain in his chest, displays the difficulty of breathing, and becomes restless. The nurse suspects fat embolism; which action of the nurse should take priority?

A. Prepare for intubation and mechanical ventilation

B. Administer IV fluids

C. Check vital signs and respiratory status

D. Notify the physician

Answer 46

Explanation

Choice D is correct. The nurse suspects fat embolism. The question provides enough information regarding the client’s distress and sudden change in his clinical status. The mortality rate with fat embolism is about 10%. Early recognition and treatment are crucial. The nurse should immediately inform the physician to initiate medical interventions.

Fat embolism is a potentially life-threatening complication that occurs from long bone fractures due to fat emboli being dislodged and traveling into the bloodstream and up into the pulmonary circulation. Symptoms mimic that of pulmonary embolism. The client may report chest pain, respiratory distress (dyspnea), and may have mental status changes (confusion). Other signs include tachypnea, low oxygen saturation, fever, tachycardia, and low blood pressure. Petechiae (axillary or subconjunctival petechiae) are characteristic of fat embolism and help differentiate it from other etiologies.

Treatment includes intravenous hydration, oxygenation, and immobilization, and fixation of the fractured limb. In severe cases of hypoxia and neurological deterioration, intubation and ventilation may be required.

Choice A is incorrect. The client may eventually need intubation and mechanical ventilation, depending on the respiratory and neurological condition. However, this is not the initial action of the nurse.

Choice B is incorrect. IV fluids may be necessary to prevent hypovolemic shock in the client, but this should be done after informing the physician.

Choice C is incorrect. There is sufficient information in the question to indicate the client’s distress. The client may need his vital signs checked and monitored; however, this does not take priority over informing the physician and starting emergency interventions.
Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 47

he nurse receives a report on four patients at the change of shift. Which patient should the nurse see first?

A. Patient with right femur fracture who complains of right leg pain.

B. Patient being treated for pneumonia with scheduled IV antibiotic due.

C. Patient with history of T6 spinal injury 6 months ago, now presents with headache.

D. Patient that is 1-day postoperative open cholesystectomy with green drainage.

Answer 47

Explanation

Choice C is correct. This patient may be developing autonomic dysreflexia, a medical emergency. One of the first signs/symptoms of autonomic dysreflexia is a severe, throbbing headache following spinal cord injury (most common in T6 and above). Patients usually develop autonomic dysreflexia one month to one year after their injury. However, it has also been described in the first days or weeks after the original trauma. Objectively, an episode is defined as an increase in systolic blood pressure of 25 mm Hg. Patients with this condition will develop dangerously high blood pressure that can result in severe, fatal diseases such as seizures, pulmonary edema, and myocardial infarction. Assessing this patient would be the nurse’s highest priority.

Choice A is incorrect. Right leg pain is expected in a patient with an acute right femur fracture. The nurse needs to address this patient’s pain, but expected outcomes would not be the highest priority.

Choice B is incorrect. Scheduled medications would not be a higher priority than the patient showing symptoms of a life-threatening complication.

Choice D is incorrect. Green drainage is expected in a patient with an open cholecystectomy due to the green color of bile in the common bile duct. The nurse should assess this patient’s drainage and progression of healing, but it would not be the highest priority.

NCSBN Client need
Topic: Establishing priorities, medical emergencies

Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1558)

Question 48

A client with bowel perforation is scheduled for surgery and has just been given his pre-operative medication, Diazepam. However, the new resident physician forgot to let the client sign the consent form. He hurriedly tries to make the patient sign the consent and asks the nurse to witness the signing. Which intervention by the nurse is most appropriate?

A. Witness the consent form.

B. Have the wife sign the consent for the patient and witness the signature.

C. Reschedule the surgery.

D. Report the physician to the nurse manager.

Answer 48

xplanation

The correct answer is B. Informed consent must always be obtained before pre-medication/ sedation. Unfortunately, in this case, it was missed. If the surgery is urgent, and a client is declared mentally or emotionally incompetent, the next of kin has the legal authority to give consent. In this case, the surgery is urgent (bowel perforation) and cannot be deferred, the patient is temporarily disabled, and therefore, the wife has the authority to sign the consent.

If the client is declared medically or emotionally incompetent to sign informed consent, it is essential to determine whether the loss of decision-making capacity is temporary or permanent. The next step is to determine whether the surgery is elective or urgent or an emergency. In cases where the function is temporarily lost, one should defer an elective surgery until it returns. In cases where surgery is an emergency, proceed based on the physician’s decision of the patient’s best interests. In cases where surgery is urgent, the patient’s surrogate can consent. However, if the capacity is permanently lost (e.g., dementia), the operation may proceed if felt to be in the patient’s best interest, unless the patient had previously refused the procedure before they lost capacity.

Informed consent is the process by which a patient is provided with information to make an informed decision regarding a proposed treatment and serves to educate patients benefits, risks, and potential complications of the proposed surgery. Patients have a right to be informed about the proposed treatment and determine whether they wish to move forward with the recommended treatment. It is essential that a patient has been allowed to ask questions and have them answered, understands the information, and is mentally competent to provide that consent.

There may be times when the patient does not meet one or more of the criteria for valid consent. It is essential to recognize those conditions where it may not be appropriate for the patient to provide consent and to follow suitable alternatives.

A Pre-medicated Patient: A patient pre-medicated/ sedated with a drug that can affect their judgment is one such situation. Informed consent must always be obtained prior to administering sedatives except in emergencies. When the medicated/ sedated patient does not understand the planned procedure or is not capable of making a reasonable decision, the procedure should be delayed until either the patient regains capacity or the determination is made that the procedure is urgent enough to warrant consent by a surrogate.

The Incapacitated or Incompetent Patient

    When the patient is unable to provide consent, there are several options based on the urgency of the situation.
    In an emergency, consent can be inferred or implied based on the physician's perceptions of the patient's best interests.
    In urgent and elective situations, consent may be obtained by an identified agent based on the patient's Advanced Directive and Power of Attorney for Healthcare, Durable Medical Power of Attorney, or a legally designated guardian.
    In the absence of an agent or guardian, a surrogate decision-maker may be used and may be defined in state statutes.
    The following classes of the patient's family, in descending order, may act as a surrogate in many states:
        The spouse unless legally separated
        An adult who shares an emotional, physical and financial relationship with the patient like that of a spouse
        An adult child
        A parent
        An adult brother or sister
        An adult grandchild
        An adult niece or nephew related by blood or adoption
        An adult aunt or uncle related by blood or adoption
        Another adult relative related by blood or adoption, who is familiar with the patient's personal values.
    In the absence of specific state law, the following individuals, in descending order of authority, may serve as a surrogate:
        The patient's spouse
        Adult child
        Parent
        Adult sibling
        Adult grandchild
        Any adult who has exhibited special care and concern for the patient and who is personally familiar with the patient's values.

When questions arise regarding surrogacy and absent emergent procedures, seek legal counsel in exceptional cases.

Choice A is incorrect. If the client is under the influence of chemical agents such as alcohol or drugs that impair decision-making capacity, the client is deemed mentally incompetent. Such a client’s signature does not hold ground legally.

Choice C is incorrect. Perforated bowel needs urgent surgery as it can be fatal. In the setting of needing immediate surgery, one should not reschedule the operation since the wife can give consent on behalf of the client.

Choice D is incorrect. A better alternative exists in the options where the Nurse can get the consent signed by the patient’s spouse. There is no need to report the physician right now to the nurse manager unless the physician insists that an incapacitated patient must sign the consent despite being offered a spousal alternative.

Reference

Ignatavicius DD, Workman LM.Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7thed. St. Louis, MO: Elsevier; 2013

Question 49

Which person would be best to assign to care for an 82-year-old patient who is being discharged today, after hip replacement surgery?

A. Licensed practical nurse with experience on a medical unit.

B. Licensed practical nurse with experience with surgical patients.

C. Licensed practical nurse with experience in long-term care.

D. Licensed practical nurse with experience in ambulatory care.

Answer 49

Explanation

Correct Answer is C. When making patient assignments matching the staff member’s area of expertise to the patient’s needs is essential. Please note that LPN is being assigned to take care of this stable patient post-discharge. The question is not asking about handling discharge teaching or discharge planning - these do not fall under the LPN scope of practice.

Choices A, B, and D are incorrect. In this case, the LPN with experience in geriatric or long-term care is the best choice. This nurse will better understand this specific patient’s needs than the nurses with medical/surgical care or ambulatory care experience.

Bloom’s Taxonomy: Analyzing
Reference:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8th Edition. Elsevier Mosby St Louis

Question 50

Which legislative initiative is the most closely related to information technology utilized in healthcare organizations?

A. The Health Insurance Portability and Accountability Act (HIPAA).

B. The state scopes of practice for the Informatics Nurse.

C. The Confidentiality and Information Security rule.

D. The Joint Commission for the Accreditation of Healthcare Organization’s ( JCAHO) standards.

Answer 50

Explanation

The correct answer is C.The Confidentiality and Information Security rule under the Health Insurance Portability and Accountability Act (HIPAA) is the legislative initiative that is the most closely and specifically related to information technology that is utilized in healthcare organizations. This rule specifically addresses the need for data security and protection.

Choice A is incorrect. The Health Insurance Portability and Accountability Act (HIPAA) is not the legislative initiative that is the most closely and specifically related to information technology that is utilized in healthcare organizations. There is another legislative initiative that is more specific to information technology than this.

Choice B is incorrect. The state scopes of practice for the Informatics Nurse are not legislative initiatives that are the most caring and specifically related to information technology utilized in healthcare organizations. Job descriptions for the Informatics Nurse may entail specifics about information technology and its security, but job descriptions are not legislated.

Choice D is incorrect. The Joint Commission for the Accreditation of Healthcare Organization’s ( JCAHO) standards address information technology and security; however, these are regulatory standards and not legislative initiatives.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 51

You are supervising a new Licensed Practical Nurse (LPN). You should let her know which of the following is inappropriate with regard to delegating a task to an Unlicensed Assistive Personnel (UAP)? Select All That Apply.

A. Delegate the task to the aide, watch her perform the task without her seeing you, and follow up to ensure the task was done correctly.

B. Delegate the task to the nurse aide, confirm her understanding, and follow up to ensure the task was done safely.

C. Delegate the task to the nurse aide, supervise if needed, and check-in after the task is complete to see if help is required.

D. Delegate the task to the nurse aide, ensure understanding of the job, and supervise the task being performed.

Answer 51

Explanation

Choices A, B, and D are correct. These are inappropriate actions while delegating a task. Delegation is transferring responsibility for a task. However, accountability for the task being performed is shared. It is the delegator’s responsibility to make sure the delegatee understands the job before handing off the burden of showing it, not after delegating (Choice B).

Supervision should be available on-site, if necessary. Specific direction by the nurse to UAP when assisting the nurse with a task and under the direct visual supervision of the nurse is not considered delegation (Choices A and D). Delegator is also responsible to follow up after the task has been completed to make sure it was done safely and correctly.

Choice C is incorrect. This is the only listed option that reflects the appropriate action when delegating an assignment to a nursing assistant.
NCSBN Client Need
Topic: Safe and Effective Care Environment;Subtopic: Coordinated Care

Resource: Fundamentals of Nursing (Taylor/Lillis/Lynn);Chapter 14: Implementing;Lesson: Delegating Nursing Care

Question 52

A five-year-old has been hospitalized for 24 hours. He is on skeletal traction for the treatment of a right femur fracture. You walk into the room and find him crying. His right foot is pale, and you feel no pulse. What is your priority nursing intervention?

A. Reassess the foot in twenty minutes.

B. Readjust the traction.

C. Administer the ordered as needed pain medication.

D. Notify the physician.

Answer 52

Explanation

Choice D is correct. The assessment findings indicate circulatory compromise to the right foot. This may be secondary to arterial injury distal to the fracture or compartment syndrome. It is an emergency and the nurse should notify the physician immediately to obtain appropriate orders for evaluation and intervention.

Choice A is incorrect. Although reassessment is important, any sign of circulatory compromise should be addressed immediately.

Choice B is incorrect. While readjustment of traction may be necessary, notifying the physician regarding the signs of circulatory impairment is of utmost importance. Physicians may decide on appropriate further interventions.

Choice C is incorrect. The nurse should give analgesics to address the child’s pain. However, the administration of pain medication will not resolve the issue of circulatory impairment and it is not the priority nursing action that should be taken.
NCSBN Client Need
Topic: Physiological Integrity;Subtopic: Physiological Adaptation
Reference:
Kozier and Erb’s Fundamentals of Nursing; Health assessment; musculoskeletal impairment.