Nursing Ethics and Client Care, Exams of Nursing

Download Nursing Ethics and Client Care and more Exams Nursing in PDF only on Docsity! NCLEX Review - Management of Verified Q&A with Rationales 2 A client is being prepped for a surgical procedure and the nurse is reviewing the informed consent with the client. The client asks, "Is there any other way to take care of this without having surgery?" The nurse has a duty to first: 1) Reassure the client that the surgery is the best treatment option 2) Tell the client if they don't want the surgery, they don't have to have it 3) Notify the surgeon that the client has additional questions about alternatives to surgery 4) Call the surgeon and cancel the surgery until the consent form is signed 3 Rationale: The client has a right to an explanation of the treatment and its expected results, anticipated risks and benefits, possible alternative treatment options and all questions answered before a consent form is signed. Remember, the client is not asking you for your opinion. The client is asking about alternative treatments for the condition. Notify the appropriate health care provider if the client needs additional information that you cannot answer. Once the client has all the necessary information then they can decide not to sign the informed content and cancel the surgery. A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? 1) Clinical specialty certification by an accredited organization 2) Complete and accurate documentation of assessments and interventions 3) Above-average performance reviews prepared by nurse manager 4) Sworn statement that health care provider orders were followed 5 2) Referral to personal care attendant and transportation services 3) Assessment of biophysical and sociocultural considerations 4) Identification of nursing diagnoses 5) Reassessment of health status and ADL ability 3, 4, 2, 5, 1 Rationale: Case management is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs. A nurse has unintentionally given an incorrect dose of medication to their client. No harm was done to the client. What is the next action, if any, required by the nurse? 1) The nurse is not required to report the mistake because the client was not harmed 2) The nurse is not responsible for the mistake because they have not been provided current education by their employer 3) The nurse will immediately be suspended and their license will be revoked 4) The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting 4 Rationale: 6 Although the client was not harmed as a result of the mistake, the incident still needs to be reported. Nurses are responsible for their practice and for staying current and competent by becoming lifelong learners. In this case, neither an immediate suspension nor revoking a license are warranted. A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects appropriate assertive communication? 1) "Would you please clarify what you have written so I am sure I am reading it correctly?" 2) "Please print in the future so I do not have to spend extra time attempting to read your writing." 3) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." 4) "I cannot give this medication as it is written. I have no idea of what you mean." 1 Rationale: Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information. All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first? 1) 62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8 2) 79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10 3) 70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery 7 4) 67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the dressing 1 Rationale: A surgical client using a narcotic PCA is at risk for respiratory depression, which is potentially life- threatening, and therefore the top priority. The other clients need assessment and attention, but the priority is given to the client with a respiratory rate of 8. Some bloody drainage on a dressing is expected after a drain is removed and of course the nurse would monitor this. Constipation is a side effect of narcotics but is not life-threatening. Pain control is also important but does not take priority over respiratory depression. The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? 1) Teach the initial ostomy care to a client and family members 2) Provide stoma care for a client with a well-functioning ostomy 3) Assess the function of a newly created ileostomy 4) Care for a recent complicated double barrel colostomy 2 Rationale: The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN. 10 explain their use and side effects of these medications." The nurse should respond with an understanding of which statement? 1) A referral is needed to the psychiatrist who should provide the client with answers to the request 2) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications 3) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication's uses and side effects 4) The client has a right to know about the use and side effects of the prescribed medications 4 Rationale: Clients have a right to informed consent, which includes detailed information about medications, treatments and diagnostic studies. The other options are incorrect approaches. A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse? 1) Check with the nurse and the client often during the shift 2) Provide an immediate one-on-one, personal in-service about the drain 3) Assign the graduated staff nurse to be transferred to another floor for the shift 4) Change the assignment; reassign the client with the lumbar drain to a different nurse 4 11 Rationale: One of the first principles of safe assignments is to match skills with the task. New nurses should not be assigned tasks for which they are not competent. The assignment needs to be changed. The other options simply help support the nurse but may be dangerous for the client. And, of course, the new nurse will need training about caring for a client with a lumbar drain. The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority). 1) Blood and sputum cultures 2) Oxygen 2 liters nasal cannula 3) Fingerstick before each meal and at bedtime 4) Ceftriaxone (Rocephin) 1 gram every 12 hours IVPB 5) IV normal saline at 100 mL/hr 2, 1, 5, 4, 3 Rationale: For establishing priorities, first look at the ABCs. Oxygen administration is the first priority (and the client's oxygen saturation is probably low given the patient has pneumonia). The next priority would be to have the lab come and draw blood for the cultures; this must be done prior to starting the antibiotics. Then an IV must be started (the antibiotic is ordered IV). Even though the patient is diabetic and it is dinner time, a finger stick is the last thing on the list to complete. A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? 1) Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care 12 2) Report to the nurse manager about the witnessed suspicious activity 3) Request to see identification and an explanation as to why the woman is viewing client charts 4) Immediately call security for this breach in client confidentiality 3 Rationale: Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation. A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse? 1) Report of unstable angina with continuous telemetry monitoring 2) Tracheostomy of 24 hours with the client showing some respiratory distress 3) Pacemaker insertion on the day shift 4) Dopamine IV drip with vital signs monitored every five minutes 3 Rationale: The nurse from the float pool should be assigned to care for the most stable client, which is the client who had the pacemaker inserted on the day shift. The other clients are unstable and have potentially 15 4) A Bosnian male, who is a certified medical interpreter 2 Rationale: When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter is needed. But, it may be inappropriate to have a male interpreter for a female client because the client may not be as forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client. The best response is to have a female interpreter who does not know the client. The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time? 1) State strongly: "Stop. Tell me why there's no urine in the tubing." 2) Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter." 3) In a speaking tone of voice, explain: "The tubing is probably in the vagina." 4) Ask the student in a calm voice: "Did you do something wrong?" 2 When no urine appears after inserting a catheter into a female client, the catheter may be in the vagina. This catheter can be left in place and used as a landmark indicating where not to insert the new, sterile catheter. The best approach is for the nurse is to calmly remind the student about this technique and offer assistance. The other options are unprofessional and/or they may upset the client and the student. 16 The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What action should the nurse take next? 1) Ask another staff nurse to discuss the same concerns with the hospitalist 2) Request a consult with the in-house pharmacist 3) Page the attending physician to express the same concerns 4) Administer the medication as ordered 3 Rationale: The scenario is an example of the "two-challenge rule." It is the nurse's responsibility to assertively voice concerns at least two times to ensure that it has been heard. If the outcome is still not acceptable, the nurse needs to take a stronger course of action by either contacting a supervisor or the attending physician to express the same concerns. The nurse must be an advocate for the client. A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) 1) Reconciliation of medications 2) Poor communication among providers 3) Client health status 4) Family preferences 17 5) Excellent primary care 2, 3, 4 Rationale: Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care. The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority ethical consideration that can help guide the nurse? 1) Nurses should not prejudge a client's pain using their own values 2) Cultural sensitivity is fundamental to pain management 3) The client's self-report of pain is the most important consideration 4) Clients have the right to have their pain relieved 3 Rationale: Pain is a complex phenomenon that is perceived differently by each individual. This is why the self- report is the most reliable way to determine a client's pain. Nurses should apply ethical standards, such as respect for autonomy (the right of people to make their own decisions about healthcare), when assessing pain. The other statements are correct but they are not the most important considerations.