MEDICAL PREP INSTITUTE OF

TAMPA BAY

Exit/Nclex
Examination
Study Guide
fjenar inc
Management of Care

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Priorty

Definition

Deciding which needs or problems require immediate action and which ones could be
delayed until later time because they are not urgent

Guidelines for prioritizing

 Nurse and client rank client’s needs

 Priorities are classified as high, intermediate, or low
 High priorities include life-threatening needs
 Nonemergency and non–life-threatening needs are intermediate
 Client needs not directly related to client’s illness or prognosis are low priorities
Setting priorities for client teaching

Review learning objectives established and determine what client perceives as

important

Prioritizing for groups of clients

 Identify problem of each client, reviewing all nursing diagnoses

 Determine most urgent needs and begin with those; then move to less urgent needs
 Factor in time it may take to care for priority needs of each client
 Involve client as much as possible in his or her care
Key words

First, Priority, Initial, Main Concern, Primary, first ,Best ,Most important, Essential,

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Clients problems that usually indicate priority

 Fresh postoperative clients ( newly arrived on nursing unit from postanesthesia care
 Clients whose status has deteriorated from baseline (vital signs, level of consciousness,
 Clients exhibiting signs of shock (hypovolemic, hemorrhagic, cardiogenic, distributive)
 Clients who have allergic reactions
 Clients who have chest pain
 Clients who have returned from diagnostic procedures and require temporary, more
intensive monitoring, including assessing for complications
 Clients who verbalize unexpected or unusual symptoms (such as new or suddenly increased
acute pain, blurred vision, sudden weakness or paralysis)
 Clients who have equipment or tubing malfunction or accident (such as disconnection of IV line,
central line, chest tube; or alarms ringing on mechanical ventilator or cardiac monitor)
 Lower priority clients are often those whose main needs include teaching, which is not as time
bound unless individual circumstances indicate otherwise
 New Admission
 MOST UNSTABLE PATIENT ALWAYS GOES FIRST
 Injuries to face, neck and chest that impairs respiration are the highest priorities
 Actual problems or needs have higher priority than potential problems or needs
 Problems or needs identified by client are of a higher priority

PRIORITY –WHICH PATIENT IS GOING DIE FIRST

MNEMONIC TO REMEMBER HOW TO ADDRESS PRIORITY

PHAN
P=PRIORITY

H= HIERARCHY (MASLOW)

A= ABC’s

N=Nursing process-(always assess before you act)

ASSESSMENT FIRST

KEY WORDS FOR ASSESSMENT

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 Adaptations  Obtain information
 Ascertain  Perceptions
 Assess  Question
 Check  Signs and Symptoms
 Collect  Sources
 Communicate  Stressors
 Determine  Verbal
 Find out  Verify
 Gather  Inspect
 Identify  Monitor
 Inform  Non verbal
 Observe  Notify

The nursing process is important when facing priority questions!

EXAMPLE

A nurse responses to the cardiac monitor alarm of a patient and observes that the patient has atrial flutter.
The patient is sitting up in the bed and is responsive. Which of the following actions should the nurse take
first.

A. Institute carotid sinus massage

B. Assess the patient for Dyspnea

C. Initiate cardiopulmonary resuscitation for the patient

D. Place the patient in Trendelenburg position.

RATIONALE

a. Carotid sinus massage (This is a procedure that is used to investigate unexplained dizziness, falls or faints)

B. Dyspnea-CHECK DIFFICULTY BREATHING.

APPLICATION OF THE NURSING PROCESS

YOU LEARN THE NURSING PROCESS SO YOU CAN BE A SAFE NURSE SO THEREFORE YOU MUST APPLY THE
NURSING PROCESS WHEN ANSWERING NCLEX QUESTIONS

ADPIE

ASSESSMENT

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DIAGNOSIS

PLANNING

IMPLEMENTATION

Nursing process- REMEMBER ASSESS FIRST BEFORE IMPLEMENTATION – ASK YOURSELF IS THERE ENOUGH
INFORMATION GIVEN TO TAKE ACTION. YOU CANNOT IMPLEMENT UNLESS YOU HAVE ENOUGH
INFORMATION

EXAMPLE

The night after an exploratory laparotomy, a patient who has a nasogastric tube attached to low suction
reports nausea. A nurse should take which of the following action first?

a. Administer the prescribed antiemetic to patient

b. Determine the patency of the patient’s nasogastric tube

c. Instruct the patient to take deep breathes

d. Assess the patient’s pain level

RATIONALE

THE PATIENT IS COMPLANING OF NAUSEA, THERE IS NO EVIDENCE OF ISSUES WITH AIRWAY OR

BREATHING.

THE QUESTION IS ASKING, WHAT IS THE FIRST THING YOU WOULD DO FOR THIS PATIENT WHO IS
REPORTING NAUSEA. The A, B, C’s are eliminated, use the nursing process, Answers A and C are
implementation. Do you have enough information to ACT. Do you know why you are acting? Assess first!

Answer D is tempting because you see the words assess, but ask yourself: IS PAIN THE ISSUE HERE,

NAUSEA IS THE ISSUE HERE. NOT PAIN. IT IS IMPORTANT TO FIGURE OUT WHATS CAUSING THE NAUSEA

ANSWER B – IS POSSIBLE WHY? PRIOR TO AN EXPLORATORY LAPAROTOMY , A PATIENT HAS A

NASOGASTRIC TUBE INSERTED TO DECOMPRESS THE STOMACH . NAUSEA CAN BE CAUSED BY DISTENTION
OR INADEQUATE DRAINAGE.

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1. ABC Come first
WHAT IF YOU DO NOT HAVE ABC’S

Airway isn’t always right!

CASE IN POINT “My toe hurts!” says the ED client. “OK, let me check your airway,” says new nurse. “I don’t
think so!” says the nursing instructor

2. Next is your patient with change in level of consciousness- safety issue

****Check LOC before check pedal pulses/ Compare current BP with previous BPs****
Table 1: Classification of Altered Levels of Consciousness

A. Confusional States- Confusion is a state in which the patient cannot take into account all
elements of his/her immediate environment, implying an element of sensorial clouding.
Apathy and drowsiness are often prominent and accompanied by disorientation primarily
for time, less often for place, and rarely for self. Motor abnormalities such as tremor,
asterixis and difficulty in motor relaxation may occur.Mild confusional states are
common, especially in elderly patients exposed to hospital care or the trauma of
major surgery

B. Delirium- Delirium is a common and difficult problem especially in ill elderly patients. It
is characterized by a fluctuating disturbance in consciousness and change in cognition that
usually develops over a short period of time. Ten to fifteen percent of elderly patients may
be delirious on arrival to the hospital and up to 55% may become delirious following
admission. Delirium is often accompanied by increased morbidity and subsequent
functional decline.

C. Obtundation - Obtundation is primarily characterized by reduced alertness and

hypersomnia. Hypersomnia is technically defined as a state of sleep in excess of 25% of the
expected normal. When awakened from an obtunded state, the patient remains drowsy and
confused and wakefulness can only be maintained by continuous verbal and painful stimuli.
It is common to see the patient spontaneously changing postures in bed, drawing up the
bed-sheets, and trying to pull out intravenous needles and indwelling catheters

D. Stupor*- Stupor is unresponsiveness from which the patient can only be aroused by
vigorous repeated painful stimuli. There is no response to verbal stimuli, and the response
to pain becomes progressively less as the level of stupor deepens. The patient is unable to
localize the site of the painful stimuli and, at best, the response is slow and stereotyped.
Mental and physical activity is reduced to a minimum. Although unresponsive to many
stimuli, the patient can open his/her eyes, look at the examiner and does not appear to be
unconscious. Deep tendon reflexes are usually intact, but there may be evidence of muscle
twitching, restless or stereotyped motor activity and grasping and sucking reflexes.

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Catatonic stupor is seen most commonly in young people affected by catatonic
schizophrenia. The patient lies with eyes open or tightly closed, resisting passive eye
opening. There is an absence of spontaneous movements.

E. Coma* - The patient who appears to be asleep and is at the same time incapable of
responding adequately to either external stimuli or internal needs is in a state of coma.
Coma may vary in degree from light to medium to deep. At its deepest stages, no reaction of
any type is obtainable from the patient. Corneal, pupillary, pharyngeal, tendon and plantar
reflexes are all absent. Opisthotonos and extensor rigidity of the limbs are suggestive of a
decerebrate state. Respirations are often slow and Cheynes-Stokes in character. In lighter
stages of coma (sometimes referred to as semicoma), most of the above mentioned reflexes
can be elicited. Very painful stimuli may cause the patient to stir or moan.

The Glasgow Coma Scale (GCS) is the most widely accepted method for the evaluation and
classification of coma, especially for head-injured patients. As shown in Table 2, the GCS
grades three neurologic parameters. Patients who open their eyes spontaneously, obey
commands and are oriented score a total of 15 points, the best possible score, whereas
flaccid patients, who neither open their eyes or verbalize, score the minimum of 3 points. A
GCS score of 8 or less is the generally accepted definition of coma. Those with a GCS of 8 or
less are classified as severe, while those with a GCS score of 9 to 12 are categorized as
moderate and those with a GCS score of 13 to 15 are mild.

Coma grades 3 to 5 indicate potentially fatal damage, especially if accompanied by fixed

pupils or absent oculovestibular responses. Conversely, scores of 9 and above correlate
with good recovery.

*Both stupor and coma are often further classified as mild, moderate or deep.

3. Infection or type of Sepsis becomes a priority (a patient with sepsis take higher priority than someone in
pain after a surgical procedure

4. LABS that directly correlate to your heart and lungs (abg show respiratory acidosis leading criteria for acute
respiratory distress syndrome, those labs directly relate to our ABC. This patient would go higher than
someone with an infection. THAT PATIENT WOULD BE A PRIORITY.

5. Does the patient have a high troponin (higher o.4) CRP, CPK ( vascular inflammation ) is this patient
having an MI ( troponin higher than .0.4) THAT PATIENT WOULD BE A PRIORITY

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NCLEX Review on Delegation and Prioritization Questions
1. A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse
has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse?
a) a client with a cast for a fractured femur and who has numbness and discoloration of the toes
b) a client with balanced skeletal traction and who needs assistance with morning care
c) a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F
d) a client who had a total hip replacement 2 days ago and needs blood glucose monitoring

2. The nurse plans care for a client undergoing a colposcopy. Which of the following actions should the
nurse take first?
a) discuss the client's fear regarding potential cervical cancer
b) assist with silver nitrate application to the cervix to control bleeding
c) provide instructions regarding douching and sexual relations
d) administer pain medication

3. A nurse is caring for four clients and is preparing to do her initial rounds. Which client should the
nurse assess first?
a) a client with diabetes being discharged today
b) a client with tracheostomy and copious secretions
c) a client scheduled for physical therapy this morning
d) a client with a pressure ulcer that needs dressing change

4. A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform
first?
a) call for help to get the client back in bed
b) establish whether the client is responsive
c) assist the client back to bed
d) ask the client what happened

5. A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate
tasks to members of the care team. The nurse preceptor recognizes that this reluctance most likely is
due to:
a) role modeling behaviors of the preceptor
b) the philosophy of the new nurse's school of nursing
c) the orientation provided to the new nurse
d) lack of trust in the team members

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6. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap.
Which should the nurse do first?

A. Check the Babinski reflex

B. Listen to the heart and lung sounds

C. Palpate the abdomen

D. Check tympanic membranes

6. A nurse is working in an emergency department and receives a client after a radiologic incident.
Which task is a priority for the nurse to do first?
a) decontaminate the client's clothing
b) decontaminate an open wound on the client's thigh
c) decontaminate the examination room the client is placed in
d) save the client's vomitus for analysis by the radiation safety staff

7. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse
make first?
a) respiratory status
b) level of consciousness
c) level of pain
d) reflexes and movement of extremities

8. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of
intermittent abdominal pain, abdominal bloating, and flatulence. Which is a priority for the nurse to
counsel the client to avoid in her diet?
a) fiber
b) broccoli
c) yogurt
d) simple carbohydrates

9. A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse
includes which of the following on the care plan as the priority complication to prevent?
a) pain
b) wound infection
c) depression
d) thrombophlebitis

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10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses
the client and notes that the client is pale and diaphoretic with blood pressure 94/60, respiration 32.
The client is anxious, fearing death. Which action should the nurse take first?
a) administer pain medication
b) administer IV fluids
c) administer dopamine
d) administer oxygen per nasal

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1) D
- a nurse from medical-surgical unit floated to the orthopedic unit should be given clients with
stable condition, and those whose care are similar to her training and experience. A client who is
2-day postop is more likely to be on stable condition. And the medical-surgical unit nurse is
competent in monitoring blood glucose.

2) B
- the priority nursing action when caring for a client who will undergo colposcopy is to assist in
controlling potential bleeding by applying silver nitrate to the cervix.

3) B
- a patient with problem of the airway should be given highest priority. ABC is a priority.

4) B
- assessing for responsiveness is the first nursing action when performing CPR.

5) D- lack of trust is the most common reason for reluctance in delegating tasks among members
of the te

6) B
- decontaminating an open wound is the first priority when caring for a client after a radiologic
incident. This minimizes absorption of radiation in the client's body.

7) A
- assessing respiratory status is the first priority when caring for a client in the post-anensthesia
care unit. ABC is a priority.

8) B
- broccoli is gas forming. This should be avoided in clients experiencing flatulence.

9) B
- wound infection is the most common complication among obese clients who had undergone
surgery. This is due to poor blood supply in the adipose tissues. Therefore, there is decreased
oxygen supply and diminished supply of protective cells in the areas.

10) D
- promotion of adequate oxygenation is most vital to life. Therefore, this should be given highest
priority by the nurse for a client with dyspnea, chest pain, and synco

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NCLEX Review on Delegation and Prioritization Questions

11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action
should the nurse take first?

a) sit the client in a geriatric chair with an activity

b) apply a vest restraint when the client is in a chair
c) apply bilateral wrist restraints when the client is in bed
d) have a staff member sit with the client at all times

12. The nurse is providing care in the emergency department to the client with chest pain. Which action
is most important for the nurse to do first?
a) perform venipuncture and start an IV line
b) administer oxygen via nasal cannula
c) administer morphine sulfate intravenously
d) start lidocaine (xylocaine) infusion

13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of
the following clients should be seen first?
a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breath
b) a 16 year old male with ecchymosis, pain, and swelling of the right arm
c) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder pain
d) an 8 year old child who is crying hysterically and reports abdominal pain

14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and
edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like
my throat is getting tight." The first action the nurse should take is:
a) assess the child's airway and breathing
b) call 911 and request an ambulance
c) administer subcutaneous epinephrine
d) remove the stinger from the foot

15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child
has apparently taken part of a bottle of adult acetaminophen capsules. The priority action for the nurse
to take first is:
a) tell the mother to position the child lying down on her side
b) tell the mother to dial 911 and request an ambulance
c) have the mother give the child a glass of milk
d) instruct the mother on how to administer syrup of ipecac

16. A nurse receives a 10-month old child with a fracture of the left femur on the pediatric unit. Which
action is important for the nurse to take first?
a) call for a social worker to meet with the family
b) check the child's blood pressure, then pulse, respiration, and temperature
c) administer pain medication
d) speak with the parents about how the fracture occurred

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17. A nurse on the cardiac unit is caring for four clients and is preparing to do initial rounds. Which client
should the nurse assess first?

a) a client scheduled for cardiac ultrasound this morning

b) a client with syncope being discharged today
c) a client with chronic bronchitis on nasal oxygen
d) a client with a diabetic foot ulcer that needs a dressing change

18. A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head.
Which action should the nurse perform first?

a) determine level of consciousness

b) push the call button for help
c) turn the client face up to assess
d) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician

19. A nurse is working on the night shift with a nursing assistant. The nursing assistant comes to the
nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain
despite multiple requests. Which of the following actions by the nurse is best?

a) ask the other nurse if she needs any help

b) assess the client, and let the other nurse know what should be done
c) ask the client if he is satisfied with his care
d) contact the nursing supervisor to address the situation

20. The nurse is reviewing immunizations with the caregiver of a 72 year old client with a history of
cerebral vascular disease. The caregiver learns that which immunization is a priority for the client?

a) hepatitis A vaccine
b) lyme disease vaccine
c) hepatitis B vaccine
d) pneumococccal vaccine

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NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

11) A
promotion of safety and providing diversional activities are priority nursing care for confused
elderly clients. Application of restraints should be the last resort. Having a staff member sit with
the client at all times is not necessary, unless the client is at risk to injury.

12) B
- administration of oxygen is a priority nursing action in a client with chest pain. The primary
reason for chest pain is inadequate myocardial oxygenation.

13) A
- the client with problem of the airway and who has unstable condition should be given highest
priority. Priority ABC.

14) A
- the situation indicates that the child is having anaphylactic reaction. The first action by the
nurse is to assess airway and breathing. Priority assessment is ABC.

15) D
- acetaminophen is non-corrosive. Therefore, inducing vomiting by administering syrup of
ipecac is appropriate management in case of acetaminophen overdose or poisoning

16) D
- in case of injury especially among children, it is very important that the nurse should first
assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.

17) C
- a client with problem of the airway should be attended first. ABC is a priority.

18) A
- assessing level of consciousness is the first action when dealing with a situation where the
client might have had a fall or when preparing to do CPR (cardio-pulmonary resuscitation).

19) D
- the RN should use proper channel of communication. The nursing supervisor is responsible for
the actions of the different members of the nursing team.

20) D
pneumococcal vaccine is a priority immunization for the elderly, especially those with chronic
illness. It is administered every 5 years.

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NCLEX Review on Delegation and Prioritization Questions

21. A nurse delegates administration of an enema to a nursing assistant. The nurse should intervene if
the nursing assistant:

a) advances the catheter 4 inches into the anal canal

b) hangs the enema bag 12 to 18 inches above the anus
c) lubricates 4 to 5 inches of the catheter tip
d) positions the client on the right side with head slightly elevated

22. A nurse is reviewing with a nursing assistant the care assignment for a client. Which of the following
statements if made by the nurse regarding care of a client with crutches is most appropriate?

a) the client needs to ambulate with crutches and a two-point gait

b) ambulate the client without weight bearing every 4 hours the length of the hall and back
c) ask the client if she understands how to use a two-point gait, if not, please explain it to the client
d) make sure the client does not bend the elbows when using the crutches

23. The home care nurse has four phone calls to answer. Which phone call should the home care nurse
respond to first?

a) a client who received chemotherapy yesterday and is reporting nausea and vomiting
b) a client who was discharged two days ago with a urinary catheter after a transurethral
prostactemomy and is reporting pink-tinged urine
c) a client with schizophrenia who says that the police has surrounded the house
d) the wife of a client with chronic heart disease who reports her husband is coughing frothy, white
secretions and became confused during the night

24. A nurse arrives on the scene of an apartment fire. Which of the following clients does the nurse
attend to first?

a) a 3-year old child who cannot find her parents and is reporting a headache
b) a 48-year old male who has burns on both hands and reports severe pain
c) an 18-year old male who jumped from a second story window and is reporting severe arm pain
d) a 28-year old woman who has burns on the face and neck and reports difficulty swallowing

25. A female college student reports to the student health center very distressed after waking up in a
male student's restroom and not remembering what happened to the night before. The first action the
nurse should take is:

a) obtain a rape kit

b) ask the client if she thinks she was raped

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c) place the client in an examining room and leave her while she puts on a gown
d) provide a quiet, private area to use for initial assessment of the client

26. A nurse recently started working in a hospital that employs unlicensed assistant personnel (UAP).
Which of the following are essential to effective delegation?

a) give the UAP written instructions for assignments

b) make frequent walking rounds to assess clients
c) delegate tasks based on the experience of the UAP
d) take frequent mini-reports from the UAP
e) have the UAP repeat instructions
f) explain unexpected outcomes of delegated tasks to the UAP

27. A nurse is teaching a class regarding lead poisoning in children to student nurses. The nursing
students learn to target which priority group of children for screening?

a) those with sickle cell anemia

b) those who live in homes built in the 1960's
c) those who live in low-income families
d) adolescents living in the inner city

28. A nurse is attending an In-service training class on delegation. The nurse learns that proper
delegation can involve which of the following? Select all that apply

a) giving authority
b) delegating nursing process
c) delegating tasks
d) delegating accountability
e) delegating responsibility
f) giving orders

29. When developing the plan of care for a client with suicidal ideation, which of the following would
the nurse anticipate as the priority?

a)Self-esteem
b)Sleep
c)Hygiene
d)Safety

30. A client in early labor is receiving oxytocin. When observing late decelerations in the fetal heart rate,
the nurse should first:

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a) Administer oxygen
b) Place her on her left side
c) Check the blood pressure
d) Discontinue the oxytocin infusion

31. A nurse employed in an emergency department is assigned to triage clients arriving to the
emergency room for treatment on the evening shift. The nurse should assign highest priority to which of
the following clients?
a) a client complaining of muscle aches, a headache, and malaise
b) a client who twisted her ankle when she fell while rollerblading
c) a client with a minor laceration on the index finger sustained while cutting an eggplant
d) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

32. The RN is planning the client assignments for the day. Which of the following is the most appropriate
assignment for the nursing assistant?
a) a client requiring colostomy irrigation
b) a client receiving continuous tube feedings
c) a client who requires urine specimen collections
d) a client with difficulty swallowing foods and fluid

33. The RN employed in a long-term care facility is planning assignments for the clients on a nursing
unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three
nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately
assign to the licensed practical (vocational) nurse?
a) the client who requires a bed bath
b) an older client requiring frequent ambulation
c) a client who requires a 24-hour urine collection
d) a client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

34. The RN has received the assignment for the day shift. After making initial rounds and checking all of
the assigned clients, which client will the RN plan to care for first?
a) A client who is ambulatory
b) a client scheduled for physical therapy at 1PM
c) a client with a fever who is diaphoretic and restless
d) a postoperative client who has just received pain and medication

35. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse
assess first?
a) a client scheduled for a chest x-ray
b) a client requiring daily dressing changes
c) a postoperative client preparing for discharge
d) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

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21) D
- the appropriate position of the client during enema administration is left lateral position to
facilitate flow of solution by gravity. Therefore, the action of the CNA in choices no. 4 needs to
be corrected.

22) B
- when delegating task, the nurse should provide complete, concrete and specific directions.

23) D
- the situation indicates development of pulmonary edema in the client with chronic heart
disease. This serious complication is a priority.

24) D
- burns on the face and neck involves obstruction of airway due to smoke inhalation. Airway is a
priority.

25) D
- this situation indicates possible rape of the client. Providing psychosocial support and ensuring
privacy for initial assessment of the client is most appropriate initial action.

26) A, B, C, D, E, F
- all of these aspects are essential fro effective delegation.

27) C
- lead poisoning is common in old houses (built in 1950's), and in places with unsanitary conditions
including soil, dust, vehicles using leaded gas. These factors are common among low-income families.

28) A, C, and E
- proper delegation involves giving authority, delegating tasks, and delegating responsibility. Nursing
process, accountability and giving orders are to be done by the RN, and not to be delegated.

29) D
- for the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-
harm or self-destruction. Although self-esteem, sleep and hygiene are common areas that require
intervention for a client with suicidal ideation, ensuring the client’s safety is the most immediate and
serious concern.

30) D
- the infusion should be stopped because it is placing the fetus in danger.

31) D
- In an emergency department, triage involves brief client assessment to classify clients
according to their need for care and includes establishing priorities of care. The type of illness or
injury, the severity of the problem, and the resources available govern the process. Clients with

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trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute
neurological deficits, and those who have sustained chemical splashes to the eyes are classified
as emergent and are the number 1 priority. Clients with conditions such as a simple fracture,
asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have
urgent needs and are classified as number 2 priority. Clients with conditions such as a minor
laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority.

32) C
- The nurse must determine the most appropriate assignment based on the skills of the staff
member and the needs of the client. In this case, the most appropriate assignment for a nursing
assistant would be to care for the client who requires urine specimen collections. The nursing
assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed
by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for
aspiration.

33) D
- When delegating nursing assignments, the nurse needs to consider the skills and educational
level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting
with frequent ambulation can be provided most appropriately by the nursing assistant. The
licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and
most appropriately would be assigned to the client who needs this care.

34) C
The RN would plan to care for the client who has a fever and is diaphoretic and restless first
because this client’s needs are the priority. Waiting for pain medication to take effect before
providing care to the postoperative client is best. The client who is ambulatory and the client
scheduled for physical therapy later in the day do not have priority needs related to care.

35) D
- Airway is always a highest priority, and the nurse would attend to the client who has been
experiencing an airway problem first. The clients described in options A, B, and C have needs
that would be identified as intermediate priorities.

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DELEGATION

The re-assigning of responsibility for the performance of a job from one person to another.

Delegation Involves

Responsibility: an obligation to accomplish a task

Accountability: accepting ownership for the results or lack of results

Authority: right to act or empower

DELEGATOR –THE PERSON ASSISGNING THE TASK.

DELEGETEE- THE PERSON BEING ASSIGNED THE TASK

UAP- Unlicensed Assistive Personnel

Five rights of delegation

 Right task
 Right circumstances
 Right person
 Right direction/communication
 Right supervision
o Right task - define the task and determine if it can be safely delegated
 match the delegatee to the task
 determine if the task is within the scope of practice for the delegatee
 determine agency policies, procedures, and standards
 understand standards of practice, e.g., the American Nurses Association (ANA)
Standards of Practice
 remember - nursing tasks that be delegated to unlicensed assistive personnel
(UAP) are intended to assist, but not replace, the nurse
o Right circumstances
 determine if there is anything about the client's condition or the environment
which would preclude this delegatee from performing the task as delegated
 determine if staff members have the resources, equipment, and supervision
needed to work safely
o Right person - is the right person delegating the right task to the right person to be performed
on the right patient?
 determine if staff members have the necessary knowledge, skills, and abilities
(KSA) to perform the delegated tasks and if this information is documented
 determine if the client's condition is stable with predictable outcomes prior to
delegating care
o Right direction/communication - clearly communicate the specific steps of the task,
expectation about performance, reporting, and documentation of the task
 potential problems and solutions are discussed
 the nurse intervenes if necessary
 staff members must be able to decline without jeopardizing their jobs

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o Right supervision/evaluation - appropriate monitoring, intervention, evaluation, and ongoing
feedback
 the nurse must have the appropriate skills to assist, teach and guide the
individual who is completing the task
 the nurse will determine if client needs were met
 the nurse can continue or withdraw the delegation
 problems, particularly and sentinel events, are clarified or reported to
supervisors

3. Delegation involves trust

Inappropriate delegation

1. Underdelegation: delegator does not think that UAP or lpn can perform or complete an
assignment or does not transfer full authority.
2. Reverse delegation: team members request that RN complete task because of inability or
Unwillingness to perform designated task or procedure
3. Overdelegation: delegator becomes overwhelmed by situation and loses control by
delegating inappropriate tasks; tasks that are beyond their scope of practice should not
be delegated to UAPs and LPN
A. The Registered Nurse can delegate to the LVN/LPN, Unlicensed Assistive Personal (UAP)
(c.na’s, pct other ancillary staff) and other RN’s

B. The LVN/LPN can delegate to the UAP

C. The UAP cannot delegate to other UAP
A. Delegation involves
1. Responsibility: an obligation to accomplish a task
2. Accountability: accepting ownership for the results or lack of
3. Authority: right to act or empower

The Delegator will transfer the responsibility of the task but not the accountability.

***EXAMPLE***

The nurse can delegate the UAP to turn the client every two hours. The UAP is responsible for
completing the task however the nurse is accountability for ensuring the task is completed safely ,
timely and in the best interests of the client. If the task is not completed, the nurse will be
responsible for explaining why the task was not completed. THUS YOU THE RN are
ACCOUNTABLE.

YOU can transfer responsibility and authority but YOU CANNOT transfer ACCOUNTABILITY so
therefore the following principles must be followed when delegating. THE RN is always
accountable

***BEFORE DELEGATION IT IS IMPORTANT TO UNDERSTAND THE RN, LPN AND UAP SCOPE OF
PRACTICE ****RN to RN assignments transfer BOTH responsibility and accountability.

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Five Rights of Delegation
✓Right Task
✓Right Circumstances
✓Right Person
✓Right Direction/Communication
✓Right Supervision/Evaluation

REGISTERED NURSE SCOPE OF PRACTICE

Registered Nurses (RNs):

Baccalaureate prepared nurses are equipped to care for individuals, families, groups and
communities in both structured and unstructured health settings
Associate degree prepared nurses are equipped to care for individuals in a structured health care
environment

SAMPLE QUESTIONS

1.A nurse recently started working in a hospital that employs unlicensed assistant personnel (UAP).
Which of the following are essential to effective delegation?

a) give the UAP written instructions for assignments

b) make frequent walking rounds to assess clients
c) delegate tasks based on the experience of the UAP
d) take frequent mini-reports from the UAP
e) have the UAP repeat instructions
f) explain unexpected outcomes of delegated tasks to the UAP

correct) A, B, C, D, E, F
- all of these aspects are essential for effective delegation

2. A nurse is attending an In-service training class on delegation. The nurse learns that proper
delegation can involve which of the following? Select all that apply

a) giving authority
b) delegating nursing process
c) delegating tasks
d) delegating accountability
e) delegating responsibility
f) giving orders

Correct A, C, and E
- proper delegation involves giving authority, delegating tasks, and delegating responsibility.
Nursing process, accountability and giving orders are to be done by the RN, and not to be delegated.

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Principles of delegation

4. A nurse can only delegate those tasks for which that nurse is responsible,
according to the specific state's nurse practice act
5. The delegator remains accountable for the task
6. Along with responsibility for a task, the nurse who delegates must also transfer
the authority necessary to complete the task
7. The delegator knows how to perform the task being delegated
8. Delegation is a contractual agreement that is entered into voluntarily
9. Consider the scope of practice of nursing personnel

REGISTERED NURSE SCOPE OF PRACTICE

a. registered nurses (RNs):

i. baccalaureate prepared nurses are equipped to care for individuals, families,
groups and communities in both structured and unstructured health settings
ii. associate degree prepared nurses are equipped to care for individuals in a
structured health care environment

The registered nurse is the leader of the team and is responsible and accountable for
providing client care. Here are just a few of the many responsibilities that the RN possesses:

 Performing head-to-toe assessment including complex and/or routine vital signs.

 Administering basic and advanced life support.
 Assessing—data collection and analysis.
 Diagnosing—identifying and prioritizing client problems.
 Planning—stating expected outcomes and methods for achievement.
 Implementing—interventions to achieve expected outcomes.
 Evaluating—analysis of plan of care and client outcomes.
 Caring for invasive lines (examples: peripherally inserted central line PICC], Swan Ganz
catheter, arterial lines).
 Feeding clients with oral or swallowing problems.
 Administering blood and blood product transfusions.
 Titrating medications based on specific client needs and physician orders.
 Performing extensive or complex dressing changes or wound care.
 Teaching of clients and families (Example: discharge teaching to parents caring for a child
with a ventriculoperitoneal shunt).
******Remember, RNs can do anything the LPN/LVN CAN DO ****

SCOPE OF PRACTICE LPN/LVN

i. assist in implementing a defined plan of care and to perform procedures

according to protocol
ii. assessment skills are directed at differentiating normal from abnormal
iii. competence to care for physiologically stable clients with predictable
conditions

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 The LPN/LVN has completed a program of study and has successfully passed the NCLEX-PN®
exam. Here we have a group of commonly permed duties of this health care provider:

 Taking routine vital signs. Did you catch the word “routine?
 Providing basic life support.
 Bathing, giving oral hygiene, and changing bed linens.
 Turning and positioning.
 Administering enemas, digital fecal removal.
 Administering medications via PO, NG, PEG, IM, Z-track, intradermal, SQ, suppository, topical,
and sublingual routes. Medication administration via the intrauretheral route is not within the
LPN/LVN’s scope of practice.
 Administering enemas, digital fecal removal.
 Administering medications via PO, NG, PEG, IM, Z-track, intradermal, suppository, topical, and
sublingual routes. Medication administration via the intrauretheral route is not within the
LPN/LVN’s scope of practice.
 Administering instillations in the eyes, ears, nose, buccal muscosa, and rectum.
 Administering enteral or tube feedings.
 Monitoring blood glucose
 Oral suctioning.
 Feeding clients without any oral or swallowing problems.
 Performing simple dressing changes (example: dry gauze dressing).
 Inserting and removing Foley catheters.
 Caring for ostomies.
 Administering respiratory treatments.
 Providing postmortem care.
 Inserting rectal tubes.
 Removing sutures and staples.
 Caring for newborns including cord care, vital signs, and feeding.
 Performing noncomplex procedures requiring sterile technique.
 Documenting the care given to the client and the client’s response to that care.
 Updating an initial assessment; the data that is collected by the LVN must be validated by the
RN
 Reinforcing the teaching performed by the RN.
 Teaching from a standard care plan, noncomplex teaching Examples: simple diabetic teaching,
simple dressing changes).’’

*****Be aware that prior to any discharge teaching, an assessment must be done by the RN to
determine what needs teaching. In an NCLEX question, however, you may have to select
appropriate discharge teaching for a LPN/LVN to complete. The key in this situation is to make
sure that what is taught is noncomplex, simple, and fairly the same tor each client****

a. Unlicensed Assistive Personnel (UAP)

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 i. because they are unlicensed, they have no scope of practice
ii. assist in a variety of direct client care activities or tasks, e.g., bathing, transferring,
ambulating, feeding, toileting, and obtaining measurements (vital signs, height, weight,
intake and output, blood glucose levels)
iii. perform indirect activities such as housekeeping, transporting people and stocking supplies

The unlicensed assistive person (UAP) provides support services to the licensed nurse during client
care. Let’s look at some of the tasks they can perform.

 Obtaining routine vital signs. Did you catch the word “ROUTINE”?
 Bathing, providing oral hygiene, changing bed linens.
 Turning and positioning.
 Feeding clients without any oral or swallowing problems.
 Providing basic life support.
 Ambulating. (Stable/noncomplex clients only)
 Obtaining height and weight measurements.
 Assisting with elimination.
 Monitoring input and output (I & O).
 Administering soapsuds enemas. PAY ATTENTION TO THIS ONE
 Assisting with general activities of daily living
 Obtaining specimens (such as a clean catch or midstream urine specimen. Or stool
specimen).
 Transferring clients with the use of proper body mechanics.
 Documenting and reporting information related to client care to the RN.
 Reporting unusual observations and symptoms reported by the client or observed to the
RN.
 Utilizing proper communication techniques (introducing self; listening to the nurse/client;
resolving conflicts or initiating resolution giving/receiving feedback).
 Prioritizing tasks (per the direction of the RN or LPN/LVN),
 Handling complaints.

***The UAP cannot perform any invasive or sterile procedures or assist in client teaching***

Reach mutual agreement about the task to be completed

the delegator validates with the delegatee that an understanding exists regarding what is to be
done and the expected outcomes potential problems and solutions are discussed

You must communicate TIME frame and the PRIORTY of the task.

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The nurse needs to ask these three questions after delegated task is completed:

a. Was the task done PROPERLY?

b. Was the task done in the proper TIME frame?
c. Were the client’s NEEDS met?

Summary of rules of Delegation

Rule #1: Do not delegate the functions of assessment, evaluation and nursing judgement. During your
nursing education, you learned that assessment, evaluation and nursing judgement are the
responsibility of the registered professional nurse. You cannot give this responsibility to someone else.
Rule #2: This is not the real world. Do not make decisions regarding management of care issues based
on decisions you may have observed during your clinical experience in the hospital or clinic setting.
Remember, the NCLEX is ivory tower nursing. The answers to the questions are found in nursing
testbooks or journals. Always ask yourself, "Is this textbook nursing care?"
Rule #3: Delegate activities for stable patients with predictable outcomes. If the patient is unstable, or
the outcome of an activity not assured, it should not be delegated.
Rule #4: Delegate activities that involve standard, unchanged procedures. Activities that frequently
reoccur in daily patient care can be delegated. Bathing, feeding, dressing and transferring patients are
examples. Activities that are complex or complicated should not be delegated.
Rule #5: Remember Priorities! Remember Maslow, the ABC's, and stable versus unstable when
determining which patient the RN should attend to fist. Keep in mind that you can see only one patient
or perform one activity when answering questions that require you to establish priorities.

YOU CANNOT DELEGATE

Planning (care plan)

Assessment (initial assessment)( Secondary assessment can be delegated not primary) First assessment
cannot be delegated.

Which patient would you delegate?

1. Would you delegate the post op patient ( needs immediate attention)

2. Would you delegate the new admit ( First assessment mu be done by nurse)
3. Would you delegate the three day chest pain
Collaboration – If a patient needs a consult

Wound consult

Therapy consult

Evaluation – evaluation goals, pain levels, trending vitals signs, outcomes. This is the role of the RN. The
LPN and UAP can collect data vitals signs but they cannot evaluate

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Teaching – You cannot delegate primary education. This primary role of an RN is teaching. LVN can
reinforce

PAY ATTENTION TO WORD LIKE CHRONIC- A PATIENT WITH CHRONIC DISEASE CAN BE DELEGATED
UNLESS THEY ARE NON COMPLIANT- EXAMPLE – A diabetic patient can be delegated unless they are
noncompliant because if they are non-compliant it means they health becomes unpredictable

REMEMBER DO NOT DELEGATE THE FOLLOWING TO UAP OR LPN OR (

a new nurse RN or LPN)
 NEW ADMISSION
Do not delegate client admission
***A new admission is considered unstable and the registered nurse must assume
responsibility for this client**.
Never delegate an assessment, especially the INITIAL assessment.

* Case in point: The only time the RN would even consider delegating an Assessment
is after the initial assessment, when you allow the LPN/LVN to do a follow-up on a
stable client. Even then, you have to validate the LPN’s or LVN’s assessment findings.
The preference on answering related test questions is to never delegate any assessement
in any form. This also includes evaluation, as evaluating a client always includes an
assessment.
Do not delegate assessment, evaluation, or nursing judgment.
***look for key words like assess, observe, teach, monitor (these words usually
identify the nursing process)***
Do not delegate any task that requires excessive problem-solving skills.

Do not delegate any task that has the slightest chance of causing harm.

Case in point: Feeding a client who has dysphagia, because the client is at risk for
aspiration. Ambulating a client who recently has had hip surgery. Taking vital signs on
client who is unstable.

Feeding, ambulating, taking vital signs would normally be routine tasks however in
this case there is potential that these may result in harm due to the instability of the
clients, so therefore they cannot be assigned to the UAP’s or LPN.

Do not delegate establishing a plan of care.

Do not delegate teaching.(lpn’s can reinforce teaching, note the words reinforce)
Do not delegate telephone advice.
Do not delegate the handling of any invasive lines. This includes central lines, arterial
lines, Swan-Ganz catheters, and PICC lines
 PATIENT WHO HAS JUST RECEIVED A SURGICAL PROCEDURE
 PATIENTS WHO NEED ADVANCED INFECTION CONTROL MEASURES

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Never delegate discharge planning or any skill that requires judgment skills ***however if a patient
is being discharged they a usually considered stable thus can usually delegated unless there is a
mention of planning the discharge.

Don’t assume someone is competent to do something just because of their JOB DESCRIPTION.

It is the RN’s REPONSIBILITY to figure out the staffs strength and WEAKNESSES
***When you(RN) identify a weakness you are supposed to TEACH. Teach, teach.***
When staff members are pulled to a new floor, you should pretend they are a brand NEW nurse all
over again.

EXAMPLE

1. During an interview of a prospective employee who just completed the agency application,
which approach should a nurse manager use to assess skills' competence of this potential
employee?
A. "Let’s review your skills check-list for type and level of skill for tasks."

B. "Let's talk about your comfort zones for working independently."

C. "What degree of supervision for basic care do you think you need?"

D. "What types of complex client care tasks or assignments do you prefer?"

RATIONALE –ANSWER A-The nurse needs to know that the potential employee has competence in
certain tasks that are common on the unit. One way to do this is to do mutual review of the agency
list of skills. The other questions might be asked during the skills checklist review.
YOU NEED TO KNOW THE NURSE CAPIBILITIES SO YOU KNOW WHAT TO ASSIGN THEM AND
WHAT YOU NEED TO TEACH. You better teach, and you had better FOLLOW Up what you taught.

Floating: When a nurse is floated to another floor, assignments must be made according to the
nurse’s ability. Assigning an ICU nurse who is floated to Labor and Delivery to take care of a patient
who is in full labor is not a good choice, nor is it wise to assign a floored nurse who is floated to the
ER to take care of a person in full cardiac arrest. On the other hand, all nurses know how to give
blood, how to interpret vital is, and how to give medications.

2. An RN with 15years experience in the Emergency Room is pulled to the labor and delivery Unit
. Which client should be assigned to this nurse.
a. The Client with DVT
b. The Client in active labor
c. The client who is 8 hours post partum
d. The client requiring fetal monitoring
RATIONALE –ANSWER A -The RN although having 15years experience in the ER is still new to the
labor and delivery floor and therefore must be considered a BRAND NEW nurse. It would be best to
assign this nurse to a patient they would be familiar with in this case the client with DVT. All the
other clients are labor and delivery clients the nurse would be unfamiliar with. IT IS BEST TO

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ASSIGN A NURSE ACCORDING TO THE BASIS OF THEIR EXPERIENCE AND SPECIALITY. A
CARDIAC NURSE COMES TO THE ER SHOULD BE ASSIGNED A CARDIAC PATIENT. A LABOR AND
DELIVERY NURSE COMES TO MEDSURG FLOOR SHOULD BE ASSISNED A PREGANT CLIENT ETC.
SO KNOW YOUR SPECIALITIES. Do not give this nurse any clients requiring any SPECIALIZED
care TO a new nurse

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 PRACTICE QUESTIONS
1. The measurement and documentation of vital signs is expected for clients in a long
term facility. Which staff type would it be a priority to delegate these tasks to?

A) Practical nurse (PN)

B) Registered Nurse (RN)

C) Unlicensed assistive personnel (UAP)

D) Volunteer

Review Information: The correct answer is C: Unlicensed assistive personnel (UAP)

The measurement and recording of vital signs may be delegated to UAP. This falls under
the umbrella of routine task with stable clients. Other considerations for delegation of care
to UAP would be: Who is capable and is the least expensive worker to do each task?

2. Which client data should the nurse act upon when a home health aide calls the
nurse from the client's home to report these items?

A) "The client has complaints of not sleeping well for the past week"

B) "The family wants to discontinue the home meal service, meals on wheels"

C) "The urine in the urinary catheter bag is of a deeper amber, almost brown color"

D) "The partner says the client has slower days every other day"

Review Information: The correct answer is C: "The urine in the urinary catheter bag is of a
deeper amber, almost brown color" Home health aides need to report diverse information
to nurses through phone calls and documentation. The nurse who develops the plan of care
for a specific client, and supervises the aide, must identify potential danger signs which
require immediate action and follow-up. The color of the urine requires follow-up
evaluation.

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3. A nurse from the pediatric unit is assigned to work in a critical care unit. Which
client assignment would be appropriate?

A) A client admitted with multiple trauma with a history of a newly implanted pacemaker

B) A new admission with left-sided weakness from a stroke and mild confusion

C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial

infarction

D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle
accident

Review Information: The correct answer is D: A 35 year-old client in balanced traction

admitted 6 days ago after a motor vehicle accident

This client is the most stable with a predictable outcome.

4. An unlicensed assistive personnel (UAP), who usually works in pediatrics is

assigned to work on a medical-surgical unit. Which one of the questions by the
charge nurse would be most appropriate prior to making delegation decisions?

A) "How long have you been a UAP?”

B) "What type of care did you give in pediatrics?”

C) "Do you have your competency checklist that we can review?”

D) "How comfortable are you to care for adult clients?”

Review Information: The correct answer is C: "Do you have your competency checklist that
we can review?” The UAP must be competent to accept the delegated task. Further
assessment of the qualifications of the UAP is important in order to assign the right task.

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5. The LPN delegates the task of taking vital signs of all the clients on the medical-
surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal
instructions are given to not take a post-mastectomy client’s blood pressure on the
left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on
that client’s left arm. Which of these statements is most immediately accurate?

A) The RN has no accountability for this situation

B) The RN did not delegate appropriately

C) The UAP is covered by the RN’s license

D) The UAP is responsible for following instructions

Review Information: The correct answer is D: The UAP is responsible for following
instructions The UAP is responsible for carrying out the activity correctly once directions
have been clearly communicated especially if given verbally and in writing.

6. The nurse in a same-day surgery unit assigns the unlicensed assistive personnel
(UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is
most appropriate?

A) "Tell the family they can bring in a pizza if the patient would prefer that."

B) "Make sure the patient gets at least 2 cartons of milk."

C) "Stop the IV if the patient is able to eat solid food."

D) "Encourage the patient to eat slowly to prevent gas."

Review Information: The correct answer is D: "Encourage the patient to eat slowly to
prevent gas."

The professional nurse can delegate tasks with an expected outcome. The UAP is given
adequate information about the task and how to promote the best outcome.

7. A staff nurse complains to the nurse manager that an unlicensed assistive

personnel (UAP) consistently leaves the work area untidy and does not restock
supplies. The best initial response by the nurse manager is which of these
statements?

A) "I will arrange for a conference with you and the UAP within the next week"

B) "I can assure you that I will look into the matter"

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C) "I would like for you to approach the UAP about the problem the next time it occurs"

D) I will add this concern to the agenda for the next unit meeting

Review Information: The correct answer is C: "I would like for you to approach the UAP
about the problem the next time it occurs"

Helping staff manage conflict is part of the manager’s role. It is appropriate to urge the
nurse to confront the other staff member to work out problems without a manager’s
intervention when possible.

8.The home care nurse has been managing a client for 6 weeks. What is the best
method to determine the quality of care provided by a home health care aide
assigned to assist with the care of this client?

A) Ask the client and family if they are satisfied with the care given

B) Determine if the home health aide's care is consistent with the plan of care

C) Investigate if the home health aide is prompt and stays an appropriate length of time for
care

D) Check the documentation of the aide for appropriateness and comprehensiveness

Review Information: The correct answer is B: Determine if the home health aide’s care is
consistent with the plan of care

Although the nurse must complete all of the above responsibilities, evaluation of an
adherence to the plan of care is the first priority. The plan of care is based on the reason for
referral, provider’s orders, the initial nursing assessment, the client’s responses to the
planned interventions, and the client’s and family’s feedback or inquires. The other
possible answers represent aspects of accomplishing “B”.

9. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with
a musculoskeletal disorder. The client ambulates with a leg splint. Which task
requires supervision of the UAP?

A) Report signs of redness overlying a joint

B) Monitor the client's response to ambulatory activity

C) Encouragement for the independence in self-care

D) Assist the client to transfer from a bed to a chair

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Review Information: The correct answer is B: Monitor the client’s response to ambulatory
activity Monitoring the client’s response to interventions requires assessment, a task to be
performed by an RN.

10. The care of which of the following clients can the nurse safely delegate to an
unlicensed assistive personnel (UAP)?

A) A client with peripheral vascular disease and an ulceration of the lower leg.

B) A pre-operative client awaiting adrenalectomy with a history of asthma

C) An elderly client with hypertension and self-reported non-compliance

D) A new admission with a history of transient ischemic attacks and dizziness

Review Information: The correct answer is A: A client with peripheral vascular disease and
an ulceration of the lower leg.

This client is stable with no risk of instability as compared to the other clients. And this
client has a chronic condition, needs supportive care.

11. When walking past a client’s room, the nurse hears 1 unlicensed assistive
personnel (UAP) talking to another UAP. Which statement requires follow-up
intervention?

A) "If we work together we can get all of the client care completed."

B) "Since I am late for lunch, would you do this one client's glucose test?"

C) "This client seems confused, we need to watch monitor closely."

D) "I’ll come back and make the bed after I go to the lab."

Review Information: The correct answer is B: "Since I am late for lunch, would you do this
one client’s glucose test?" Only the RN and PN can delegate to UAPs. One UAP cannot
delegate a task to another UAP. The RN or PN is legally accountable for the nursing care.

12. Which task for a client with anemia and confusion could the nurse delegate to the
unlicensed assistive personnel (UAP)?

A) Assess and document skin turgor and color changes

B) Test stool for occult blood and urine for glucose and report results

C) Suggest foods high in iron and those easily consumed

D) Report mental status changes and the degree of mental clarity

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Review Information: The correct answer is B: Test stool for occult blood and urine for
glucose and report results

The UAP can do standard, unchanging procedures that require no decision making.

13. During the interview of a prospective employee who just completed the agency
orientation, which approach would be the best for the nurse manager to use to
assess competence?

A) "What degree of supervision for basic care do you think you need?"

B) "Let’s review your skills check-list for type and level of skill"

C) "Are you comfortable working independently?"

D) "What client care tasks or assignments do you prefer?"

Review Information: The correct answer is B: "Let’s review your skills check-list for type
and level of skill". The nurse needs to know that the employee has competence in certain
tasks. One way to do this is to do mutual review of documented skills.

14. Which statement by the nurse is appropriate when giving an assignment to an

unlicensed assistive personnel (UAP) to help a client ambulate for the first time after
a colon resection?

A) "Have the client sit on the side of the bed before helping the client to walk."

B) "If the client is dizzy ask the client to take some slow, deep breaths."

C) "Help the client to walk in the room as often as the client wishes."

D) "When you help the client to walk, ask if any pain occurs."

Review Information: The correct answer is A: "Have the client sit on the side of the bed
before helping the client to walk."

This statement gives clear directions to the UAP about the task and is most closely
associated with the information provided in the stem that this is the client’s first time out of
bed after surgery.

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15.Two people call in sick on the medical-surgical unit and no additional help is
available. The team consists of an RN, an LPN and an unlicensed assistive personnel
(UAP). Which of these activities should the nurse assign to the UAP?

A) Assist with plans for any clients discharged

B) Provide basic hygiene care to all clients on the unit

C) Assess a client after an acute myocardial infarction

D) Gather the vital signs of all clients on the unit

Review Information: The correct answer is B: Provide basic hygiene care to all clients on
the unit

Basic client care, which is routine, should be delegated to a UAP since the unit is short on
help. The vital signs can be done by the RN and PN as they make rounds since this data is
more critical to making decisions about the care of the clients.

16.A newly admitted older adult client is diagnosed with severe dehydration. When
planning care for this client, the nurse should assign which task to an unlicensed
assistive personnel (UAP)?

a. Converse with the client to determine if the mucous membranes are impaired

b. Report hourly outputs of less than 30 mL/hr within 15 minutes of the check

c. Monitor client's ability for movement in the bed from side to side

d. Check skin turgor every four hours along with the need to change the adult diaper

Answer B- When assigning a UAP, the nurse must communicate clearly about each
delegated task with specific instructions on what must be reported and when. Because the
RN is responsible for all care-related decisions, only routine tasks should be assigned to
UAPs because they do not require judgments and decisions.

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16. The hospital is planning to downsize and eliminate a number of staff positions as
a cost-saving measure. To assist staff in this change process, the nurse manager is
preparing for the "unfreezing" phase of change. With this approach the nurse
manager should take what action?

A. Discuss with the staff how to deal with any defensive behavior

B. Clarify what the changes mean to the community and hospital

C. assist the staff for an acceptance of the new changes

D. explain to the unit staff why change is necessary

Answer D : The first phase of change, unfreezing, begins with awareness of the need
for change. This can be facilitated by the manager who clearly understands the need
and stands behind it and explains this to the staff. The phase is completed when the
staff comprehend the need for change.

17. I’m an ER nurse with 15 years of experience and I get pulled to the Labor and
Delivery Unit. Which client are you going to give me?

a. The client with a severe DVT .

b. The client in active labor

c. The client who is 8 hours post-partum or

d. The client requiring fetal monitoring

Answer A. The client with a severe DVT . ALL THE OTHER CLIENTS ARE LABOR AND
DELIVERY PATIENTS AND THE ER NURSE IS NOT EXPERIENCED WITH THEM

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 MANAGEMENT AND DELEGATION

A. Review standards and/or position statements of the following agencies before

delegating any nursing tasks
1. State board of nursing
2. National Council of State Boards of Nursing (NCSBN)
3. Nursing organizations
a. American Nurses Association (ANA)
b. National League for Nursing (NLN)
4. Health care institutions

What is the Board of Nursing -The governing board in each state that oversees the statutory
laws. Each Board of Nursing is there to oversee implementation of the Nurse Practice Act .

***EACH STATE HAS ITS OWN STATE BOARD OF NURSING ****

***EACH BOARD OF NURSING HAS ITS OWN NURSE PRACTICE ACT **

Nurse Practice Acts

A. Definition: passed by each state legislature to regulate the practice of nursing in that
state
B. Nurse practice acts define
1. Scope of practice- Establishes guidelines by which nurses can perform
skills or services.
2. Is a set of statues ( rules and regulations ) that provide guidance to
professional nurses
3. Establishes Education, Examination, licensure and behavioral standards for
nurses that protect public
C. The Nurse Practice Act is Administered by the board of nursing in each state
1. The nurses must know how their state defines professional misconduct
2. For professional misconduct, the state board of nursing imposes penalties
(in order of severity)

1. REVOCATION: Licensee's privilege to practice either as a practical (LPN) or professional (RN)

is revoked for a period. This person may not practice for the stipulated time frame.
2. VOLUNTARY SURRENDER: Accept a voluntary surrender of a license certificate.
3. SUSPENSION: The period of suspension prevents the licensee from working as a practical
(LPN) or professional (RN) nurse for definite or indefinite period of time.
4. PROBATION: All licensed nurses (LPN or RN) on probation have work conditions and may have
other mandated requirements. EMPLOYERS must be presented with a complete copy of the
licensee's Probated Order, including findings of fact, conclusions of law, and terms of the order.
5. DECREE OF CENSURE: This disciplinary action is a public reprimand by the Board of Nursing
for a violation of the Nurse Practice Act. It is in the form of a written document and does not
impose any conditions on the practical or professional license.
6. STAYED DISCIPLINARY ACTION: An action which is stayed will not be in effect unless the
licensee violates any conditions of an order. For example, a nurse on probation with a stayed
suspension is able to work under the stipulations of the probation order. If the nurse violates
any condition of the order, the license is immediately suspended.

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7. LICENSE DENIED: An applicant for licensure by either examination or endorsement may have
their application denied. They will not be granted a license.
8. CIVIL PENALTY: A monetary penalty for each violation of the Nurse Practice Act.

Possible reasons for disciplinary action or sanction include the following

1. Professional misconduct
2. Negligence- conduct that could negatively affect public health and welfare (by commission or
omission)
3. Accepting and carrying out assignments incorrectly or with insufficient preparation.
4. Physical or verbal abuse
5. Breach of confidentiality
6. Improper delegation
7. Failure to maintain accurate records
8. The impaired nurse
9. The nurse who violates boundaries ( Sex with patient, taking money etc)
National Council of State Boards of Nursing (NCSBN)

The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose
purpose is to provide an organization through which boards of nursing act and counsel together on
matters of common interest and concern affecting the public health, safety and welfare, including
the development of licensing examinations in nursing.

American Nurses Association (ANA)

The American Nurses Association is a professional organization to advance and protect the
profession of nursing. The American Nurses Association (ANA) publishes its Standards of
Nursing Practice, which defines the responsibilities of the RN to all clients for quality of care

AMERICAN NURSING CODE OF ETHICS

Provision 1
The nurse, in all professional relationships, practices with compassion and respect for the
inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of
social or economic status, personal attributes, or the nature of health problems.

Provision 2
The nurse's primary commitment is to the patient, whether an individual, family, group, or
community.

Provision 3
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the
patient.

Provision 4
The nurse is responsible and accountable for individual nursing practice and determines the
appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient
care.

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Provision 5
The nurse owes the same duties to self as to others, including the responsibility to preserve
integrity and safety, to maintain competence, and to continue personal and professional growth.

Provision 6
The nurse participates in establishing, maintaining, and improving health care environments and
conditions of employment conducive to the provision of quality health care and consistent with
the values of the profession through individual and collective action.

Provision 7
The nurse participates in the advancement of the profession through contributions to practice,
education, administration, and knowledge development.

Provision 8
The nurse collaborates with other health professionals and the public in promoting community,
national and international efforts to meet health needs.

Provision 9
The profession of nursing value, for maintaining the integrity of the profession and its practice,
and for shaping social policy.

STANDARDS OF CARE

Each institution ( THE FACILITY I.E nursing home, hospital) sets standards of care, both
across the institution and for specific clinical populations

National League for Nursing (NLN)

The National League for Nursing is the preferred membership organization for nurse faculty
and leaders in nursing education.

Don't Confuse these!

Scope of Practice - determined by a state's Nurse Practice

Act

Standards of Practice - established by the nursing

profession, i.e., the American Nurses Association

Standard of Care - institutional policy and procedure

documents

PRACTICE QUESTIONS

1. Which professional organizations are responsible for establishing the codes of ethics?

40
a. American Nurses Association, National League of Nursing, and American Association of Nurse
Executives

b. International Council of Nurses, Canadian Nurses Association, and American Nurses Association

c. International, national, state, and provincial nursing associations

d. State Boards of Nursing, state and national organizations, and specialty organizations

Answer D. State Boards of Nursing, state and national organizations, and specialty
organizations

2. Which of the following phrases describes one of the purposes of the ANA's nursing's social
policy statement?

a. to describe the nurse as a dependent caregiver

b. To provide standards for nursing educational programs

c. to regulate nursing research

d. to describe nursing's values and social responsibility

Answer D -The nursing's social policy statement describes the values and social responsibility of
nursing. The American Nurses Association (ANA) publishes its Standards of Nursing Practice, which
defines the responsibilities of the RN to all clients for quality of care. ANA also publishes a code of
ethics for nurses

3. What is the purpose of the ANA's Scope and Standards of Practice?

a. To describe the ethical responsibility of nurses

b. To define the activities that are special and unique to registered nursing practice

c. To establish nursing as an independent and free standing profession

d. To regulate the practice of nursing

Answer C. The ANA's Scope and Standards of Practice define the activities of nurses that are
specific and unique to registered nursing practice

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 4.A graduate nurse is preparing to apply to the State Board of Nursing for licensure to
practice as a registered professional nurse. What group primarily is protected under the
regulations of the practice of nursing?

a. The public
b. Practicing nurses
c. The employing agency
d. People with health problem

ANSWER A. Each state or province protects the health and welfare of its populace by regulating
nursing practice through the nurse practice act Each Nurse Practice act defines 1. Scope
of practice (What each nurse professional is allowed to so or not to do. Licensure and
Education ( Diploma or Degree , advanced practice i.e LPN. RN, ARNP )

5. A nurse and teacher are discussing legal issues related to the practice of their
professions. The teacher asks what the functions are the Nurse Practice Act in that state.
The nurse would include which thoughts in a response? Select all that apply.

a. Accredit schools of nursing

b. Enforce ethical standards of behavior
c. Protect the public
d. Define the scope of nursing practice
e. Determine liability insurance rates

ANSWER C, D A stat e’s nurse practice act serves to protect by setting minimum
qualifications for nursing in relation to skills and competencies . One way it fulfills
responsibility to protect the public is defining the scope of nursing practice in that state.
The state board of nursing approves schools to operate but does not accredit them. The
state board of nursing does not enforce ethical standards, the NPA enforce legal
ramifications based on the Law (statue not ethics) Although some of the law have basis
on ethics the NPA is a set of laws not ethics.. A state NPA has no role in setting liability
insurance rates for nurse.

6. A pediatric nurse receives a subpoena in a court case involving a child. Before appearing in court,
what should the nurse review in addition to the State Nurse Practice Act and the ANA Code for
Nurses?
A. Nursing's Social Policy Statement
B. State law regarding protection of minors
C.ANA Standards of Clinical Nursing Practice
D. References regarding a child's right to consent

Answer C. These guidelines govern safe nursing practice; nurses are legally responsible to perform
according to these guidelines.

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7. A nurse observes that a client received pain medication 1 hour ago from another nurse but the
client still has severe pain. The nurse has previously observed this same occurrence. On the basis
of the nurse practice act, the observing nurse plans to do which of the following?
a. Report the information to the police.
b. Call the impaired nurse organization.
c. Talk with the nurse who gave the medication.
d. Report the information to a nursing supervisor.

Rationale: Answer D Nurse practice acts require reporting the suspicion of impaired nurses. The state
board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and
supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the
board of nursing. Options 1 and 2 are inappropriate. Option 3 may cause a conflict.
8. The Registered Nurse working in the emergency room observes that his co-worker is not performing
well in providing care to the client. He suspects that his /her co-worker is substance impaired and
notes signs of alcohol intoxication. The Nurse Practice Act requires that the Registered Nurse do
which of the following

a. ask the colleague to go to the nurse’s lounge to sleep for a while

b. talk with the colleague
c. report the information to a nursing supervisor
d. call the impaired nurse organization

ANSWER: C-RATIONALE: The Nurse Practice Acts requires reporting the suspicion of the impaired
nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for
treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then
report to the Board of Nursing. Confronting the colleague may cause conflict. Asking the colleague to go
to the nurses’ lounge to sleep for a while does not safeguard clients.

9. A registered nurse suspects that a colleague is substance impaired and notes signs of
alcohol intoxication in the colleague. The Nurse Practice Act requires the registered nurse do
which of the following?

a) talk with the colleague

b) call the impaired nurse organization

c) report the information to a nursing supervisor

d) ask the colleague to go to the nurse's lounge to sleep for a while

10) C -- Nurse Practice Acts require reporting the suspicion of impaired nurses. The Board of
Nursing has jurisdiction over the practice of nursing and may develop plans for treatment
and supervision. This suspicion needs to be reported to the nursing supervisor, who will
then report to the Board of Nursing. Confronting the colleague may cause conflict. Asking the
colleague to go to the nurses' lounge to sleep for awhile does not safeguard clients.

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 LEGAL RESPONSIBILITIES

Negligence: legally, a breach of the duty to provide nursing care to the client - The unintentional failure
of an individual to perform or not perform an act that a reasonable person would or would not perform in a
similar set of circumstances

b. Negligence involves four legal concepts:

1. Duty: nurses have a legal obligation to provide nursing care to clients
a. must meet a reasonable and prudent standard of care under the circumstances
b. must deliver care as any other reasonable and prudent nurse of similar education and experience would,
under similar circumstances
2. Breach of duty: failure to provide expected, reasonable standard of care under the circumstances
(includes errors of omission or commission)
a. Proximate cause: relationship between the breach of duty and the resulting injury
b. the injured party must prove that the nurse's action or omission led to the injury
3. Damages: the injury and the monetary award to the plaintiff

A person who files a lawsuit must prove four essential elements

The nurse had a duty to care for the patient and follow acceptable standards of care , the nurse
failed to provide care or adhere to the standards of practice and because of this breach of duty
this resulted in patient injuries (proximate cause . the breach of duty must directly relate to injuries)

c. Malpractice is professional negligence – professional failure to carry out or perform duties that result in
injury to another, acting outside one’s scope of practice

1. Boundaries of malpractice are defined by statute, rules and educational requirement

2 .Malpractice is usually filed as a civil tort, a court finding or guilty usually results in restitution.

2. Rarely are malpractice charges filed as criminal charges

What is the Difference between Negligence and Malpractice

Negligence is the failure to act as a reasonably prudent (careful) person would have acted in a specific
situation and harm occurs to the patient. Malpractice is negligence by a professional person during the
performance of professional duties. Malpractice refers to a professional.
LEGAL CHARGES

 Assault : threat of harm or unwanted contact with s clients that causes the client fear

*******KEY ELEMENTS- FEAR AND INTIMIDATION – SAYING OR DOING SOMETHING

TO MAKE A PERSON AFRAID THAT HE OR SHE WILL BE TOUCHED WITHOUT
CONSENT******

 Battery is intentionally touching the client’s body without the client’s permission.
Ask what is difference between Assault (verbal such “if you don’t get up and walk you
can’t watch TV”) and Battery (physical contact such as forcing the client to get up and
walk).
KEY ELEMENT –CONSENT UNLIKE ASSAULT , ACTUAL CONTACT IS ESSENTIAL

 FORCING A PATIENT TO TAKE MEDICATION

 STRIKING A PATIENT

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  PERFORMING A PROCEDURE WITHOUT CONSENT

 False imprisonment is an action by which the client is restrained or held captive without
medical order. And prohibiting a client from leaving a facility with no legal justification.

 CONFINEMENT CAN BE PRODUCED BY PHYSICAL, EMOTIONAL OR CHEMICAL

MEANS
 Fraud is an intentional deceptive act or statement to a client for the purpose of unlawful
gains.
 Negligence is when a resident is harmed due to care giver not acting in reasonable and
caring manner towards the resident.
 Invasion of privacy is violating the privacy of the client by sharing their patient
information other personal information.
 Libel is making false statement in print or in writing.
 Slander is making false statements (spoken) which may injure the reputation of a client.
 Sexual battery can be defined as any nonconsensual touching of the client.
 Defamation of character : sharing client information with a third party that result in
damage to client’s reputation : can occur in form of slander (spoken) or libel (in writing

HIPAA Health Information Portability and Accountability Act 1996

•This legislation, better known by most as HIPAA, describes how personal health information, or
PHI, may be used and how the client can access the information.
•HIPAA requires every healthcare agency to keep PHI private, provides information to the client
about the agency’s legal responsibilities regarding privacy, and explains the client’s rights with
respect to PHI.
•The client has various rights as a consumer of health care under HIPAA.
•The client who feels that his or her privacy rights have been violated may file a complaint with the

1. The nurse is in the hospital’s public cafeteria and hears two nursing assistants talking about Ms. R
in 406. They are using her name and discussing intimate details about her illness. Which of the
following actions is best for the nurse to take?
a. Go over and tell the nursing assistants that their actions are inappropriate, especially in public
place
b. Wait and tell the assistants later that they were overheard discussing the client. Otherwise, they
might be embarrassed.
c. Tell the nursing assistants’ supervisor about the incident. It is the supervisor’s responsibility to
address the issue
d. Say nothing. It is not the nurse’s job and she is not responsible for the assistants’ actions

Answer A. It is the preferred answer because right there in then you will be able to stop the discussion
of the patient’s case in front of a lot of people. Option B may be correct because you are saving from
humiliation the nursing assistance but it is not the preferred answer because doing so will allow
further discussion of the case and more harm will be committed. Option C may be correct because in
the first place you are not their immediate superior but not appropriate in this situation because it
will further the discussion of the case thus allowing a lot of people to overhear it. Option D is the

45
 worst thing to do since you will not do anything to prevent it from happening.

2. Ms. R is a client on your medical-surgical unit. His cousin is a physician and wants to see the chart.
Which of the following is the best response for the nurse to take?
a. Hand the cousin the client’s chart to review
b. Ask Ms. R to sign an authorization, and have someone review the chart with the cousin
c. Call the attending physician and have the doctor speak with his cousin
d. Tell the cousin that the request cannot be granted

Answer B. The owner of the chart is the patient himself so it is a must that before authorizing any
individual to view the chart, authorization should secured and have someone review the chart with
the patient’s physician cousin. Options A, C and D are the incorrect way of dealing such situations
involving the patient’s chart.

Good Samaritan Law

Laws designed to provide legal immunity to health care professionals that assist at the scene
of an emergency as long as their assistance meets two criteria:

a. It is the type of assistance that reasonably a prudent person with a similar background would
give in a similar circumstance.

b. It is not grossly negligent.

 The focus is limited to emergencies away from the workplace. So if a neighbor asks you to
give his daughter a weekly allergy shot, the nurse does not have the same protection or
obligation you’d have in an emergency. If you were to give this non-emergency care and the
child was injured, you could be held liable.

 When the emergency ends, the Good Samaritan protection ceases and does not extend beyond
the scene of the emergency. For example, ensuring that a patient who is bleeding after a car
accident is stabilized is covered by the good Samaritan law however transporting the
patient in your own car is not covered.

1. A nurse comes up a motor vehicle accident when driving to work. The nurse administers
care to the people involved. Under the Good Samaritan Act, the nurse could be liable:
a. For nothing, any action is covered
b. For gross negligence
c. For not providing the standard care found in the hospital
d. For not stopping and offering care

Answer A.Good Samaritan Act protects those who choose to lend a hand during emergency situations.
In this act, the nurse is not liable to any laws once she helps an injured individual during this emergency.
Options B, C and D are incorrect because these do not explain what the act is all about.

Reporting to external authorities or governing bodies The following must be reported

 Gun shot wounds

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 Rape
 Abuse
 Domestic Violence
 Dog bites

Nurses and physicians are also required to report evidence of crunes (such as homicide,
suicide. Inflicted injury such as stab or gunshot wounds, and abuse) to police

Telephone Triage: Information about patient condition cannot be divulged over telephone
regardless of who the person on the other end says he/she is. Divulging information violates patient
privacy act and constitutes invasion of privacy. The most you can say is that the patient is at your
facility – UNLESS it is a psychiatric patient. In that case, you cannot even admit to the patient’s
presence. Doing so could be considered a breach of confidentiality and can be construed as
negligence. An RN or LPN cannot and should not give. Advice or counsel over the telephone

47
PRACTICE QUESTIONS
1. A client had a colon resection. A Salem tube was in place when a regular diet was brought into the
client's room. The client did not want to eat solid food and asked that the health care provider be
called. The nurse persisted in the belief that the solid food was the correct diet. The client ate two
meals and subsequently had additional surgery due to complications. The nurse understands that
the determination of negligence in this situation is based on:
a. A duty existed and it was breached
b. Not calling the health care provider
c. The dietary department sending the wrong food
d. The nurse's beliefs
Rationale: Answer A Proven negligence requires a duty, a breach of duty, the breach of duty must
cause the injury, and damages or injury must be experienced. Options B, C, and D do not fall under the
criteria for negligence. Option A is the only option that fits the criteria of negligence

3. A client arrives in the emergency room and is assessed by the nurse. The client complains of a
headache from drinking alcohol and asking for medication. The nurse explains to the client that
assessment must be performed first before the administration of any medication. The client
becomes verbally abusive and the nurse threatens to place the client in the restraints. Which of
the following that the client can legally charge the nurse?

a. Assault
b. Negligence
c. invasion of privacy
d. battery

ANSWER: A-RATIONALE: An assault occurs when a person puts another person in fear of a harmful of
offensive contact

4. A nurse is discussing to the nursing students about the right of the clients. The nurse asks the
student to identify a scenario that would represent invasion of privacy of the client. Which of the
following, if identified by the nursing student, indicates an understanding of a violation of this client
right?

a. threatening to give a client a medication

b. performing a procedure without consent
c. telling the client that he/she cannot leave the hospital
d. observing care provided to the client without the client’s permission

ANSWER: D -RATIONALE: Invasion of privacy takes place with unreasonable intrusion into an
individual’s private affairs.

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5.The nursing instructor provides a lecture to the nursing students regarding some rights of the clients.
The instructor asks the student to identify a situation that represents an example of battery. Which of the
following items indicates an understanding of a violation of this right?

a. performing a procedure without consent of the client

b. sharing the client’s record to other personnel not involve in providing care
c. threatening the client that he cannot leave the hospital
d. threatening to give a client a medication

ANSWER: A -RATIONALE: Performing a procedure without consent of the client is a form of battery.
Threatening the client to give medication is an example of assault. Threatening the client cannot leave the
hospital constitute false imprisonment and sharing the client’s data is a form of invasion of privacy.

2. The nursing staff taking their morning breaks. One of the nursing assistants tells the group that the
ward supervisor has acquired immunodeficiency syndrome. The nursing assistant proceeds to tell the
nursing staff that the supervisor probably got the disease from her drug addict husband. Which legal
tort has the nursing assistant violated?

a. Libel
b. Slander
c. Assault
d. Negligence

ANSWER: B -RATIONALE: Slander or Defamation takes place when something untrue is said about a
person resulting injury to that person’s good name and reputation.

7.A nurse is administering a medication to a client but refuses to take the prescribed medication. The
nurse threatens the client telling if the medication is not taken orally, then it will be given by injection. This
action by the nurse constitutes which legal tort?

a. invasion of privacy
b. negligence
c. assault
d. battery

ANSWER: C -RATIONALE: An assault occurs when person puts another person in fear of a harmful or
offensive contact. For this intentional tort to be actionable, the client must be aware of the threat.

8.A client is scheduled for a cardiac catheterization and has numerous questions regarding the procedure
and has requested to speak to the physician. The nurse calls the physician and informs that the client
wants to talk to him. When the physician arrives at the unit to visit the client he is very upset with the
nurse. The nurse is outside the client’s room and hears the physician tells the client in a derogatory
manner that the nurse “doesn’t know anything”. Which legal tort has the physician violated?

a. Slander
b. Libel
c. Assault
d. Negligence

ANSWER: A -RATIONALE: Slander/Defamation takes place when something untrue is said (slander) or
written (libel) about a person resulting in injury to that person’s good name or reputation

49
9. A client has returned to the nursing unit after surgery. A nurse is assigned to monitor the client’s
condition. Over the past four hour, the client’s vital signs are deteriorating and the nurse does not
recognize the significance of these changes in vital signs and take no action. The client later requires
emergency surgery. The nurse could be prosecuted for inaction according to the definition of which of
these terms?

a. Tort
b. Misdemeanor
c. Common Law
d. Statutory Law

ANSWER: A-RATIONALE: Tort is a wrongful act intentionally or unintentionally committed against a

person or his or her property. The nurse’s inaction in the situation described is consistent with the
definition of a tort offense.

10. A client, which as a famous police officer, is admitted to the hospital with a diagnosis of
Parkinson’s disease. The nurse gives medical information regarding the client’s condition to a
person who is assumed to be a family member. Later, the nurse found out that this person is not
a family member of the client and the nurse realizes that she has violated which legal concept of
the nurse-client relationship?

a. performing focused physical assessment

b. client’s right to privacy
c. nurse’s lack of experience
d. teaching and learning principles

ANSWER: B-RATIONALE: Discussing a client’s condition without client permission violates a client’s
right and places the nurse on legal jeopardy. This action by the nurse is both an invasion of
privacy and affects the confidentiality issue with the client rights.

11. A nurse was hired to be a home care nurse to assist the family in caring for a newborn with
congenital tracheoesopahgeal fistula who is receiving enteral feedings. The nurse receives a
telephone call and a woman introduced herself to the nurse as a family friend and wishes to know the
condition of the client and inquire if there is anything she can do to assist the parents. The best
nursing action is to:

a. inform the friend that the family has no need for assistance at this time because the
nurse is making daily visits
b. inform the friend to directly contact the family and offer her assistance to them
c. report the friend’s telephone call to the nurse manager for referral to the client’s social
worker
d. request that the friend come to the client’s home, where she can be taught to administer
the feedings

ANSWER: B-RATIONALE: A nurse must uphold the client’s rights and does not give any information
regarding a client’s care needs to anyone who is not directly involved in the client’s care. To
request that the friend come for teaching is a direct violation of the client’s right to privacy. There
is no information in the question to indicate that the family desires assistance form the friend. To
refer the call to the nurse manager and social worker again assumes that the friend’s assistance
and involvement is desired by the family. Informing the friend that the nurse is visiting daily is
providing information that is considered confidential.

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 12. A nurse is assigned to care for a male client recovering home from a disabling lung infection. In
her assessment of the health history of the client, the nurse found out that the infection is probably
the result of HIV. The nurse is a religious person and informs the client that she is morally opposed to
homosexuality and cannot care for him. The nurse then leaves the client’s home. Which of the
following is true regarding the nurse’s actions?

a. the nurse has a duty to provide competent care to assigned clients in a nondiscriminatory
manner
b. the nurse has the right to refuse to care for any client without justifying that refusal
c. the nurse has the duty to protect self from client care situations that are morally repellent
d. the nurse has a legal right to inform the client any barriers in providing care

ANSWER: A -RATIONALE: The nurse has a duty to provide care to all clients in a nondiscriminatory
manner. Personal autonomy does not apply if it interferes with the rights of the clients. There is
no legal obligation to inform the client of the nurse’s personal objections to the client. Refusal to
provide care may be acceptable if that refusal does not put ht e client’s safety at risk and the
refusal is primarily associated with religious objections, not personal objection to lifestyle or
medical diagnosis. The nurse also has an obligation to observe the principle of nonmaleficence

13. A client who had a colon resection is given a regular diet. The client refuses to eat solid food and
asked that the physician be called. The nurse insisted that the solid food is an advised diet. The client
was convinced and ate the food that was offered. Subsequently, the client had emergency surgery as
a result of complications. The determination of negligence in this situation is based on:

a. the nurse’s persistence

b. a duty existed and it was breached
c. not calling the physician
d. the dietary department sending the wrong food

ANSWER: B-RATIONALE: For negligence to be proven, there must be a duty, and then a breach of
duty; the breach of duty must cause the injury and damages or injury must be experienced.

14.A nurse lawyer is conducting an educational session to the nursing staff regarding client rights. The
nursing staff requested the lawyer to give an example that may give them a clear idea relating to invasion
of client privacy. Which of the following indicates a violation of this right?

a. performing a surgical procedure without consent

b. telling the client that he/she cannot leave the hospital
c. taking photographs of the client without consent
d. threatening to place a client in restraints
ANSWER: C-RATIONALE: Invasion of privacy takes place when an individual’s private affairs are
unreasonably intruded into.

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15. The day shift nurse receives report for a critically ill client who has pneumonia and is on a
ventilator. The departing nurse shares the vital signs with the day nurse and reports that the
temperature and blood pressure are within normal limits. When the day shift nurse performs an
assessment, the client's temperature is 104.8° F. After checking the previous shift's vital signs, the
nurse notes that the last time the temperature was taken was at midnight. It was now 8 am and the
patient begins to seize. The nurse on duty knows:

A. Causation occurred

B. There was no foreseeability

C. Duty had not occurred since the client's first night shift nurse went home with the flu.

D. The night shift nurse should be fired for negligence.

Correct Answer: Causation occurred A. Objective: Discriminate between negligence and malpractice.

Rationale: Negligence is misconduct or practice that is below the standard expected of an ordinary,
reasonable, and prudent person. Malpractice is professional negligence that occurred while the person
was performing as a professional.

16. A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks
the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that
indicates a violation of this right

A.Threatening to place a client in restraints

B.Performing a surgical procedure without consent

C.Taking photographs of the client without consent

D.Telling the client that he or she cannot leave the hospital

Rationale:

Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably.
Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without
consent is an example of battery. Not allowing a client to leave the hospital constitutes false
imprisonment.

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17. An older woman is brought to the emergency department. When caring for the client, the nurse
notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the
client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence
that her daughter frequently hits her if she gets in the way. Which of the following is the appropriate
nursing response?

A."I have a legal obligation to report this type of abuse."

B."I promise I won't tell anyone, but let's see what we can do about this."

C."Let's talk about ways that will prevent your daughter from hitting you."

D."This should not be happening. If it happens again, you must call the emergency department."

Rationale:

Confidential issues are not to be discussed with nonmedical personnel or with the client's family or
friends without the client's permission. Clients should be assured that information is kept confidential
unless it places the nurse under a legal obligation. The nurse must report situations related to child,
older adult abuse, and other types of abuse depending on state laws; gunshot wounds; stabbings; and
certain infectious diseases

18.A client arrives in the emergency department and is staggering, confused, and verbally abusive. The
client complains of a headache from drinking alcohol and is asking for medication. The nurse explains to
the client that the health care provider will need to perform an assessment before the administration of
medication. When the client becomes verbally abusive, the nurse threatens to place the client in
restraints. With which of the following can the client legally charge the nurse as a result of the nursing
action?
A. Assault

B. Battery

C. Negligence

D. Invasion of privacy

Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive
contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or
offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the
standards of care. When the individual's private affairs are unreasonably intruded upon, invasion of
privacy occurs.

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19. A nurse calls the health care provider (HCP) of a client scheduled for a cardiac catheterization
because the client has numerous questions regarding the procedure and has requested to speak to
the HCP. The HCP is very upset and arrives at the unit to visit the client after prompting by the
nurse. The nurse is outside the client's room and hears the HCP tell the client in a derogatory
manner that the nurse "doesn't know anything." The nurse plans to address the HCP's remark,
understanding that the HCP has violated which legal tort?
A.Libel
B.Slander
C.Assault
D.Negligence

Rationale:
Defamation is a false communication or careless disregard for the truth that causes damage to
someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person
puts another person in fear of a harmful or offensive contact. Negligence involves the actions of
professionals that fall below the standard of care for a specific professional group.

20. A nurse witnesses an automobile accident and provides care at the scene of the accident to an open
wound on a young child. The family is extremely grateful and insists that the nurse accept monetary
compensation for the care provided to the child. Because of the family's insistence, the nurse
accepts the compensation to avoid offending the family. The child develops an infection and sepsis
and is hospitalized. The family files suit against the nurse who provided care to the child at the scene
of the accident. The nurse understands that which of the following is accurate regarding immunity
from this suit?
A. Good Samaritan laws will protect the nurse.

B. Good Samaritan laws protect laypersons and not professional health care providers.

C. Good Samaritan laws will protect the nurse if the care given at the scene was not negligent.

D. Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation
for the care provided.
Rationale:
A Good Samaritan law is passed by a state legislature to encourage nurses and other health care
providers to provide care to a person when an accident, emergency, or injury occurs, without fear
of being sued for the care provided. Called "immunity from suit," this protection usually applies
only if all the conditions of the law are met; for example, the health care provider receives no
compensation for the care provided, and the care given is not willfully or wantonly negligent.

21. A client was involuntarily admitted to the psychiatric unit because of episodes of extremely
violent behavior. The client is demanding to be discharged from the hospital. The RN does not allow

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the client to leave. The RN understands that which of the following represents the legal ramifications
associated with the RN's behavior?
a. The RN will be charged with assault.
b.The RN will be charged with slander.
c.The RN will be charged with imprisonment.
d.No charge will be made against the RN, because the RN's actions are reasonable.

Rationale: False imprisonment is an act with the intent to confine a person to a specific area. A nurse
can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the
client was voluntarily admitted and if there are no agency or legal policies for detaining the client. On
the other hand, if the client has been involuntarily admitted or has agreed to an evaluation before
discharge, the nurse's actions are reasonable.
22. The nurse says. “If you do not let me do this dressing change, I will not let you eat dinner
with other residents in the dining room”. This is an example of:
a. Assault
b. Battery
c. Negligence
d. Malpractice

Answer A. Assault is threatening or attempting to inflict injuries to the patient. The verbalization of the
nurse clearly shows that it is a case of an assault. Option B is touching the patient without consent. This
is done by pinching or slapping the patient. Options C and D are forms of violations that the nurse can
commit to a patient in line with the patients profession

23. An anxious patient repeatedly uses the call bell to get the nurse to come to the room.
Finally the nurse says to the patient, “If you keep ringing, there will come a time I won’t answer
the bell.”This is an example of:
a. Slander
b. Assault
c. Battery
d. Libel

Answer B. This is a case where the nurse committed an assault as manifested by the threatening
behaviour of the nurse. Option A is achieved when you speak ill of a person. Option B is putting the
threatening behaviour into action. Option D is committed when one talks ill of another through writing it
in a published form.

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56
ETHICAL PRINCIPLES
a. Ethics
i. A theory or system of moral values, based on the ideas of right and wrong
ii. It governs our relationships with others
b. A code of ethics provides standards and values for a profession; individuals must integrate the
values of the profession with their own values

ANA – PROVIDES A CODE OF ETHICS FOR REGISTERED NURSES

i. Autonomy –Freedom to make decisions for self and take action for self, is self governing ,
includes four basic elements , Respect for others, ability to determine personal goals , complete
understanding of choice and freedom to implement plan or choice.
ii. Nonmaleficence - "do no harm" ( either intentional or unintentional)
iii. Beneficence - do good and avoid evil (to act in the best interests of others client advocacy,
has three major components: to promote good, prevent harm or evil, and remove harm or
evil.
iv. Justice- Fair equitable and appropriate treatment , resources are distributed equally to all
v. Veracity - the ethical duty to tell the truth
vi. Confidentiality –maintaining clients privacy
vii. Fidelity - loyalty, faithfulness and honoring commitments and promises.

1. A client is referred 1 to a surgeon by the general practitioner. After meeting the surgeon, the
client decides to find a different surgeon to continue treatment. The nurse supports the client’s
action, utilizing which ethical principle?

a. Beneficence
b. Veracity
c. Autonomy
d. Privacy
Answer C-Autonomy is tithe right of individuals to autonomy is the right of individuals to take
action for themselves. Beneficence is an ethical principle to do good and applies when the nurse has
a duty to help others by doing what is best for them. Veracity refers to truthfulness. Privacy is the
nondisclosure of information by the health care team.

NCLEX KEY STRATEGY – The core issue of the question is the ability to interpret which principle is
operating in a specific situation. Eliminate privacy because it does not apply to the situation as
described. Eliminate beneficence and veracity next because they focus on the obligation of the
nurse rather than on a right of the client.

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2. A client asks why a diagnostic test has been ordered and the nurse replies, “I’m unsure but will
find out for you.” When the nurse later returns and provides an explanation. The nurse is acting
under which principle?

a. Nonmaleficence
b. Veracity
c. Beneficence
d. Fidelity

Fidelity means being faithful to agreements and promises. This nurse is acting on the client’s
behalf to obtain needed information and report it back to the client. Nonmaleficence is the duty
to do no harm. Veracity refers to telling the truth for example, not lying to a client about a
serious prognosis. Beneficence means doing good, such as by implementing actions

NCLEX KEY STRATEGY Use the process of elimination. The correct answer is the one that
matches the description in the stem; that is, the nurse made to a promise to a client and kept it,
which constitutes fidelity.
3. A client with cancer has decided to discontinue further treatment. Although the nurse would like
the client to continue treatment, the nurse recognizes the client is competent and supports the
client’s decision using which ethical principle?

a. Justice
b. Fidelity
c. Autonomy
d. confidentiality
Answer C Autonomy refers to the right to make own decisions, which is the principle supported
in this tuition. Justice refers to fairness. Fidelity refers to trust and loyalty. Confidentiality refers
to the right to privacy of personal health information. Confidentiality refers to the right to
privacy of personal health information.
4. A client with leukemia is being considered for a bone marrow transplant. The healthcare team is
discussing the risks and benefits of this treatment and other possible treatments with the goal of
inflicting the least possible harm on the client. Which principle of healthcare ethics is the team
practicing?

A) Justice
B) Fidelity
C) Autonomy
D) Nonmaleficence
Correct answer(s): D
Nonmaleficence - "do no harm" ( either intentional or unintentional)-

5. Which action by the nurse represents the ethical principle of beneficence?

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A) The nurse upholds a client’s decision to refuse chemotherapy for lung cancer.
B) The nurse follows a plan of care designed to relieve pain in a client with cancer.
C) The nurse administers an immunization to a child even though it may cause discomfort.
D) The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.

Correct answer(s): C -Remember: Beneficence - do good and avoid evil (to act in the best
interests of others client advocacy, has three major components: to promote good, prevent
harm or evil, and remove harm or evil. Immunization is preventive measure which will protect
the client from harm from a specific disease . A is out this deals focus on the clients right does
not prevent harm for the client B. would be good choice however this is focusing on comfort
rather than prevention of harm. D is justice remember Fair equitable and appropriate
treatment, resources are distributed equally to all.

6. Dilemmas regarding ethical principles are common in health care. Which ethical principles
commonly associated with client care in the health care setting? Select all that apply.
a. Autonomy: the freedom to make choices for one’s self without interference from others.
b. Moral distress: the health care professional knows the ethically correct action to take, but is
either legally or professionally prohibited from acting on that knowledge.
c. Beneficence: the concept of doing good and preventing harm to clients.
d. Fidelity: the concept of faithfulness and promise-keeping to clients, including client
confidentiality.

Answer: A, C, & D. The ethical principles commonly associated with health care/client care
Issues are autonomy, beneficence, nonmaleficence. ‘Veracity, fidelity, and justice. Moral distress
is not an ethical principle, but a moral-ethical dilemma.

7. In the health care setting, the ethical principle OF “justice” refers to which aspect of client
care?
A. each client’s right to access to their own medical records and health information.
B. Each client’s constitutional right to health care.
C. The most appropriate allocation of scarce health care resources.
D. The right to equal health care, regardless of the client’s condition.

Answer: C. The ethical principle of “justice,” in the health care setting, refers to the appropriate
allocation of scarce health care resources with regard to client care. The client’s right to access
their own health information and medical records is guaranteed under HIPAA, the Health
Insurance Portability and Accountability Act of 1996. The constitution does not guarantee the
client the right to receive health care but guarantees that access to health care be provided to all
persons.

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8. The ethical principles most commonly associated with health care and client care decisions are
autonomy, beneficence, nonmaleficence. Veracity, fidelity, and justice. Informed consent for
invasive procedures involves which of these ethical principles.
A. Autonomy, beneficence, nonmaleficence. Veracity, and fidelity.

B. Autonomy, beneficence, veracity, fidelity. And justice

c. Beneficence, nonmaleficence, veracity. Fidelity, and justice.
d. Autonomy and nonmaleficence only.

Answer: A. Informed consent for invasive procedures involves the ethical principles of
autonomy, beneficence, nonmaleficence, veracity, and fidelity. Justice, as an ethical principle,
relates to the ethically appropriate allocation of scarce health care resources and generally does
not factor into the informed consent process.

9. Which of the following terms are moral principles? Select all that apply.
a. Autonomy
b. Beneficence
c. Ethics
d. Fidelity
Answer: A, B, D Objective: Explain how nurses use knowledge of values to make ethical
decisions and facilitate ethical decision making by clients. Rationale: Fidelity means being
faithful to an agreement or promise. The nurse promises to return with the client's medication.
This represents fidelity. Justice represents fairness. Beneficence represents "doing good," but is
a term generally used when discussing legal issues. Ethics typically refers to ideals and values.

10. The nurse did not follow hospital procedure and hung a unit of blood on the wrong client. The
client had an anaphylactic reaction and the team is called in for emergency treatment. During
the resuscitation, the nurse does not reveal that the wrong blood was given. Which moral
principles were violated? Select all that apply.

a. Veracity
b. Fidelity
c. Beneficence
d. Autonomy

Answer A. C- Objective: When presented with an ethical situation, identify the moral issues and
principles involved. Rationale: The moral principle of veracity refers to telling the truth, no
matter the outcome. By lying, the nurse jeopardized the health of the client. Beneficence means
"doing good."

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 ADVANCE DIRECTIVES

NCLEX: As part of the Omnibus Budget Reconciliation Act (OBRA) of 1990, Congress established
the Patient Self-Determination Act; this requires states to provide written information to clients
outlining their rights to make health care decisions

Clients have rights and these rights include:

a. the right to refuse or accept treatment

b. the right to formulate advance directives

 The Patient Self-Determination Act of 1990 requires hospitals to inform their patients about
advance directives.

 Advance directives are legal documents that allow someone to convey his or her decisions when
he or she is unable to make a decision.

 Anyone age 18 and older may prepare advance directives.

 Copies of any advance directives should be kept on file in the physician's office and in the
hospital.

 Advanced directives include

o Living wills
o Durable power of attorney for health care

Nurses and other members of the health care team are required to

1. Assess the clients knowledge of advance directives and their status regarding the advance
directive process
2. Provide information and assistance to the client in developing advance directives
3. Plan care that incorporates the clients decisions regarding advance directives. Three
common advance directives are:
Living Will: A living will is a legal written document; it is sometimes called a "health care
declaration" or a "health care directive" in some states. Identifies what a client wishes for his
care should he become unable to communicate these wishes

 Although it is recommended, a person does not need a lawyer to draw up a living will.
 A living will should be signed, dated, and witnessed by two people who are not related and are
not potential heirs or a health care provider.
o A person indicates what, if any, type of life-prolonging medical care should be provided if he or
she becomes terminally ill, permanently unconscious, or in a vegetative state.

 A living will goes into effect when the person is no longer able to make his or her own decisions.
(*** a living will only goes into effect when the person is no longer able to make decisions for
themselves***) Must be witnessed by at least two people who are not related or potential
heirs or health care provider ( THE NURSE CANNOT BE A WITNESS)

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  Health care proxy also called durable power of attorney for health care decisions: the
client has appointed a person (usually family or trusted friend) to make decisions about
their care if they are unable to do so. Durable power of attorney for health care
o Durable power of attorney for health care is a signed, dated, and witnessed document
naming another person to make medical decisions should someone be unable to make a
decision at any time, not just at the end of life.
 Most states do not allow the appointed agent to act as a witness.
 Although it is recommended, a person does not need a lawyer to draw up a
durable power of attorney for health care.
o The document is also known as a "health care proxy" or "appointment of a health care
agent."
o The named person may be called a "health care agent" or "surrogate."
o This document includes instructions about treatment one wants or wishes to avoid, e.g.,
surgery or artificial nutrition and hydration.
o This document goes into effect when the physician declares that a person is unable to
make his or her own medical decisions.

 All states legally recognize some form of advance medical directive.

 Do not resuscitate (DNR) status: this has been expanded to include identification of medications
that may be given without any defibrillation attempts (comfort measures only)

Who can consent to a DNR order for children?

A DNR order can be entered for a child with the consent of the child’s parent or guardian. If the
child is old enough to understand and decide about CPR, the child’s consent is also required for a
DNR order.

COPY OF ADVANCE DIRECTIVES MUST BE IN THE CLIENTS CHART

 follow the facility policy on obtaining and implementing DNR orders

 generally, the order must be written by a physician; some facilities may have a
policy to allow verbal orders under specific conditions
 the order must be communicated clearly to all personnel caring for the client
 the client or her or his health care proxy can withdraw the order at any time
 a nurse who attempts to resuscitate a client with a valid DNR order may be
committing battery

Organ/Tissue donation

1. Clients 18 years of age or older may choose to donate organs

2. Consent can be given through will, advance directive, or donor card
3. Decision can be made in advance when client is have and competent or by family at time of
death. THE LAW DOES NOT REQUIRE FAMILIES TO ADHERE TO DONOR’S WISHES TO
DONATE
4. All 50 states utilize Uniform Anatomical Gift Act to procure cadaver organs for transplant
i.Uniform Anatomical Gift Act—lists who can provide informed consent for donation of
deceased client’s organs.

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 ii.United Network for Organ Sharing—sets criteria for organ donations.
Transplant considerations

1. Bereaved family must be approached with compassion by defined personnel m requesting a

discussion on organ donation. THE LAW DOES NOT REQUIRE FAMILIES TO ADHERE TO
DONOR’S WISHES TO DONATE
2. Goal is to assist those in need of transplant with organ necessary to prolong life
3. Clinical death is defined as having no brain waves, no spontaneous breathing, and no superficial
or deep reflexes
4. Transplant team recovers organs after consent is obtained

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1. A nurse enters a client's room and notes that the client's lawyer is present and that the client is
preparing a living will. The living will requires that the client's signature be witnessed, and the
client asks the nurse to witness the signature. Which of the following is the appropriate nursing
action?
A. Decline to sign the will.

B. Sign the will as a witness to the signature only.

C. Call the hospital lawyer before signing the will.

D. Sign the will, clearly identifying credentials and employment agency.

Rationale: Living wills are required to be in writing and signed by the client. The client's signature
either must be witnessed by specified individuals or notarized. Many states prohibit any employee
from being a witness, including a nurse in a facility in which the client is receiving care.

2. A client informs the nurse during the hospital admission assessment that he does not have an
advance directive, but designates the daughter to make health care decisions in the event that
he becomes incapacitated or unable to make informed decisions. Which nursing actions are
appropriate for this client? Select all that apply.
A. Document the client’s statement in the client’s own words.
B. Provide information on advance directives to the client.
C. Inform the client that personnel are available to assist with completing an advance directive
if the client wishes to do so.
D. The nurse inquiring about a client’s advance directive could cause the client anxiety and
concern, and should be avoided.
Answer: A, B, & C. The nurse should document the client’s statement in the client’s own words. The
nurse should provide the client with information on advance directives and reassurance that there
are hospital personnel to assist with completing the advance directive. The nurse who avoids
inquiry about a client’s advance directive is not serving the client’s best interests. The nurse should
explain to the client that the law requires all clients to be asked about the existence of an advance
directive at the time of hospital admission. Inquiring about a client’s advance directive does not
indicate that the client’s health status is deteriorating or is expected to deteriorate. Preparing an
advance directive ensures that the client’s wishes will be followed in the event that the client is
unable to make health care decisions.

3. A Durable Power of Attorney for Health Care is an example of (select all that apply):
a. An advance directive.
b. A legal document that identifies a surrogate decision-maker for the client’s financial
natters in the event that the client becomes incapacitated.
c. A legal document that identifies a surrogate decision-maker in the event the client
becomes incapacitated or unable to make informed health care decisions.
d. A legal document that becomes a permanent part of the client’s medical record.

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Answer: A, B, & C. A Health Care Durable Power of Attorney is one example of an advance
directive. Advance directives are documents signed by a competent person giving direction to
health care providers about treatment choices in certain circumstances. A Durable Power of
Attorney for Health Care is a legal document that identifies a surrogate decision-maker in the event
the client becomes incapacitated or unable to make informed health care decisions. The document
becomes a permanent part of the client’s medical record. A legal document that identifies a client’s
surrogate for financial matters is incorrect because a Durable Power of Attorney for Health Care
identifies a surrogate decision maker for health care decisions only; this document does not
designate a surrogate for financial matters.

4. A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years
old and has successfully been treated for heart failure, he notes that the client is not breathing. If
the client does not have a do-not-resuscitate (DNR) order, the nurse should:

A) Call the client’s physician

B) Contact the nursing supervisor for directions

C) Administer cardiopulmonary resuscitation (CPR)

D) Administer oxygen to the client and call the physician

Correct answer(s): C-.A DNR order indicates that a client does not want treatment in the event of
respiratory or cardiac arrest. Providing treatment to a client who desires no treatment is
considered battery. The nurse and health care personnel providing treatment without the client’s
consent are liable for the treatment provided. . In this case the client does not have any advance
directives therefore the nurse can provide life prolonging procedures in this case CPR.

5. A physician informs a nurse that the husband of an unconscious client with terminal cancer will
not grant permission for a do-not-resuscitate (DNR) order. The physician tells the nurse to perform
a “slow code” and let the client “rest in peace” if she stops breathing. How should the nurse
respond?

A) Telling the physician that “slow codes” are not acceptable

B) Telling the physician that the client would probably want to die in peace

C) Telling the physician that all of the nurses on the unit agree with this plan

D) Telling the physician that if the client stops breathing, the physician will be called before any
other actions are taken

Correct answer(s): A Slow codes are considered dishonest, crass dissimulation and unethical this
is because physicians and nurses should not perform half-hearted resuscitation efforts. Options B is
out because the client does not have a DNR therefore they must attempt resuscitation. Options C
AND D ARE also out.

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6. A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The
nurse understands that:

A) The DNR order may not be changed once it is in effect

B) The DNR order requires frequent review as specified by state or agency policy

C) The only people who may change the DNR order are members of the client’s immediate family

D) The DNR order, as written on admission, must remain in effect for the duration of the client’s
hospitalization

Correct answer(s): B . DNR must be renewed. A DNR is the responsibility of the client if the
client is competent to make that decision. Terminally ill clients are not requested to
complete a DNR, but they are frequently asked to designate a person with power of attorney
for health care decisions and to complete a living will. If no durable power of attorney or
living will exists, the decision then rests with the immediate family. Most DNR orders are
reviewed every 3 days for hospitalized clients. The family may or may not agree with the
client's decision.

7. The nurse is reviewing with the client and his wife the preparation and signing of his advance
directives, including his natural death act (living will) and durable power of attorney for health
care. What will the nurse explain to the client regarding the purpose of these documents?

A. These are documents that designate how the client wants to be cared for if he is not competent to
make decisions.

B. These are legal document designating a person who is to make all of the client's financial and
health care decisions if he is not competent to do so.

C. These types of documents are only valid if the client is undergoing a procedure.

D. The documents advise physicians regarding the type of treatment the client wants and does not
want if he is not competent to tell them.

Answer A -The natural death act, or living will, provides a written statement detailing how the
client wants to be cared for should certain medical situations occur when the client is not
competent to make the decisions. The durable power of attorney for health care designates
someone of the client's choice to carry out the directions stated in the natural death act (living will).
It does not designate types of treatment for the physician. All clients receiving Medicare benefits
are required to have advance directives when admitted to the hospital. These documents are
appropriate only for matters pertaining to health care.

8. A nurse enters a client's room and notes that the client's lawyer is present and that the client is
preparing a living will. The living will requires that the client's signature be witnessed, and the
client asks the nurse to witness the signature. Which of the following is the appropriate nursing
action?

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a. Decline to sign the will.

b.Sign the will as a witness to the signature only.

c.Call the hospital lawyer before signing the will.

d.Sign the will, clearly identifying credentials and employment agency.

Rationale: Answer A Living wills are required to be in writing and signed by the client. The client's
signature either must be witnessed by specified individuals or notarized. Many states prohibit any
employee from being a witness, including a nurse in a facility in which the client is receiving care.

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INFORMED CONSENT

A legal protection of client’s right to choose type of care desired and make own decisions about health
care. Required before care is provided except in an emergency situations or when’ client is
unresponsive (assumption is that client would consent if able) at times in emergency situation family
might be required to give consent . According to the American Medical Association (AMA), informed
consent is a process of communication between a physician and a client that results in the client's
authorization or agreement to undergo a specific medical intervention.

a. Basic requirements
i. capacity
ii. voluntariness
iii. information

 Informed consent is both an ethical obligation and a legal requirement is all 50 states.

 A mentally competent adult client must give his/her own consent; parents or legal guardians may
give consent for minors.

 A client needs to understand the following information before giving consent:

o The diagnosis
o The nature and purpose of the treatment or procedure
o Any reasonable alternatives, regardless of the cost or coverage by insurance
o Risks, consequences, and benefits of the procedure and the alternative(s)
o Risks and consequences if the treatment or procedure is refused

The care provider ( doctor) has the legal obligation to obtain informed consent for medical treatment, but the
nurse should confirm consent and answer the client's questions NURSE MAY WITNESS INFORMED
CONSENT - DO NOT CONFUSE THIS WITH ADVANCE DIRECTIVES .

INFORMED CONSENT- NURSE CAN WITNESS

ADVANDED DIRECTIVE- NURSE CANNOT WITNESS ONLY THE SOCIAL WORKER CAN DO THIS

 The nurse's role in informed consent

o The nurse's role is
 to be the client's advocate
 to protect the client's dignity
 to identify any fears
 to determine the client's degree of comprehension and approval of the care he or
she is to receive
o The nurse may be assigned the task of obtaining and witnessing the client's signature
o The nurse who is concerned about the validity of an informed consent has a legal obligation
to tell the physician and the nursing supervisor about the concern.
o The nurse is not responsible for providing details about the treatment or procedure

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Exceptions to informed consent

 An emergency
 The patient has waived the right to be informed (he doesn’t want to know the risks, benefits, and so
on). You must document clearly if he waives his right.
 The health care provider believes the information would harm the patient or prevent him him
receiving life saving treatment (called therapeutic privilege)
 The patient has already given informed consent on the same type of treatment id doesn’t want to go
through the informed consent process again

A physician can legally provide immediate treatment without consent to save a patient’s life, or to
prevent loss of an organ or a function, if the patient is unconscious or, in the case of a minor, the
family cannot be reached.

Implied consent is obvious in the patient’s behavior, such as rolling up her sleeve to have blood
drawn. When the patient signs a general consent form at admission, she consents to treatments such
as 1. V. infusions and routine testing. However, implied consent Isn’t necessarily informed consent:
The patient may offer her arm so you can insert an I.V, but may not know why it’s necessary, how
long the infusion will last. Or what fluids will be infused. Implied consent isn’t sufficient if procedures
such as an I.V. infusion can cause serious risks and adverse reactions. For example, if your patient is
receive chemotherapy, a signed consent form is needed.
MINORS AND INFORMED CONSENT

Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation,
independent living or service in the military. Therefore, this married client has the legal capacity of an adult.
Otherwise, the age for legal signatures is 18 years of age.

Who cannot provide consent?

 Minors: A parent or guardian must give consent. Mentally retarded individuals

 Unconscious patients: consent is obtained from the closest adult relative.
 Mentally ill persons. Confused, disoriented or sedated
Freedom of Religion and Informed Refusal: Jehovah’s Witnesses who need blood transfusions may refuse
treatment on the basis of freedom of religion. Christian Scientists are opposed to many medical interventions
including medicines. PATIENTS HAVE THE RIGHT TO REFUSE CARE

The refusal ot treatment requires that the patient possesses decision-making capacity; must be
voluntary, and the patient must refuse reatment with knowledge and understanding of the refusal.
Record the patient’s refusal in your nurse’s notes.

1. Which of the following would the nurse identify as an indication that the client understands the
informed consent document?
a. The client states that the physician has explained the procedure to him.

b. The nurse finds the informed consent form already signed.

c. The client can give a return verbal explanation of the informed consent document.

d. The client states that his wife read it and said it was okay.

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Answer C The client needs to show an understanding of the informed consent document by giving
an explanation in his own words. He should also be able to tell you what he expects to happen
regarding the procedure, as well as the possible complications. It is the physician's responsibility to
provide the client with this information. It is not the wife's responsibility to have read it and be
agreeable because it is the client giving the informed consent.

2. Ms. R has been medicated for her surgery. The operating room (OR) nurse, when going through the
client’s chart, realizes that the consent form has not been signed. Which of the following is the best
action for the nurse to take?
a. Assume it is emergency surgery and the consent is implied
b. Give the consent form and have the client sign it
c. Tell the physician that the consent form is not signed
d. Have a family member sign the consent form

Answer C. Consents allow the physician to do the medical procedures indicated for the patient. Prior to
procedure, it is the doctor’s responsibility to obtain the patient’s consent and it is the responsibility of
the nurse to let the patient sign the consent prior to the surgical procedure. Consent unsigned is like
consent not given so it is a must that the nurse should tell the situation to the doctor performing the
surgery. Options A, B and D are incorrect because they violate the legalities of the consent.

3. A nurse is asked to sign as a witness on an informed consent form. What is the legal implication
of the nurse signing this form?
a. The client authorizes the surgeon to perform whatever procedure necessary to promote quality
of life.
b. The client appears competent and has voluntarily signed the consent form and the nurse has
witnessed the client's authentic signature.
c. The client understands all the risks associated with the procedure and wishes to continue with
the procedure.
d. The physician has explained all of the required information to the client and the client agrees
with the physician.
Answer b -The nurse's signature indicates or verifies that the client's consent was voluntary, the
client was competent to give consent, and the signature is authentic. If the nurse suspects that the
client does not understand the procedure, the nurse should notify the physician. It is unethical to
witness a consent form if the nurse does not feel that the client has been properly informed. It is the
responsibility of the physician to make sure the client understands the procedure and the risks
involved. The nurse's signature does not indicate the client agrees with the procedure and does not
verify that the client has authorized the physician to continue with treatment.

4. What should the nurse do initially when obtaining consent for surgery?

a. Describe the risks involved in the surgery.

b. Explain that obtaining the signature is routine for any surgery.
c. Witness the client's signature, which the nurse's signature will document.
d. Determine whether the client's knowledge level is sufficient to give consent.
Answer D Informed consent means the client must comprehend the surgery, the
alternatives, and the consequences. Option A. THIS IS NOT within nursing's domain the
physician is responsible for this. Option B -Although this is true, it does not determine the

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client's ability to give informed consent. Option d. Although this is true, the nurse should
first assess the client's knowledge of the surgery

5. The family of an older adult who is aphasic reports to the nurse manager that the primary nurse
failed to obtain a signed consent before inserting an indwelling catheter to measure hourly
output. What should the nurse manager consider before responding?
a. Procedures for a client's benefit do not require a signed consent.
b. Clients who are aphasic are incapable of signing an informed consent.
c. A separate signed informed consent for routine treatments is unnecessary.
d. A specific intervention without a client's signed consent is an invasion of rights.
Answer C -This is considered a routine procedure to meet basic physiologic needs and is
covered by a consent signed at the time of admission. Option A IS WRONG because -The need
for consent is not negated because the procedure is beneficial. Option B - This treatment
does not require special consent Option D This treatment does not require special consent.

6. A client is voluntarily admitted to a psychiatric unit. Later, the client develops severe
pain in the right lower quadrant and is diagnosed as having acute appendicitis. How
should the nurse prepare the client for the appendectomy?
A. Have two nurses witness the client signing the operative consent form.
B. Ensure that the surgeon and the psychiatrist sign for the surgery because it is an emergency
procedure.
C. Ask the client to sign the operative consent form after the client has been informed of the
procedure and required care.
D. Inform the client's next of kin that it will be necessary for one of them to sign the consent
form because the client is on a psychiatric unit.

ANSWER C. Because the client is not certified as incompetent, the right of informed
consent is retained.

7. What should the nurse consider when obtaining an informed consent from a 17-year-old
adolescent?

A. If the client is allowed to give consent

B. The client cannot make informed decisions about health care.
C. If the client is permitted to give voluntary consent when parents are not available
D. The client probably will be unable to choose between alternatives when asked to consent.
ANSWER A- A person is legally unable to sign a consent until the age of 18 years unless the
client is an emancipated minor or married. The nurse must determine the legal status of the
adolescent.

8.Emergency surgery is scheduled for a client with a bowel obstruction. The Registered Nurse (RN)
is unable to obtain informed consent from the client because the client has received opioid
analgesics and is very sedated. The RN understands that which of the following is the appropriate
action?

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 A. Performing the surgery without an informed consent
B. Calling the family and telling them that they must come to the hospital immediately to sign
the informed consent
C. Obtaining a telephone consent from the family member and ensuring that the oral consent is
witnessed by two persons
D. Having the client sign the consent form because this is an emergency situation
Rationale: Answer C Every effort must be made to obtain permission from a responsible family
member to perform surgery if the client is unable to sign the consent form. Telephone consent must
be witnessed by two persons who hear the family member's oral consent. The two witnesses then
sign the consent and document the name of the family member, noting that an oral consent was
obtained. In emergencies, the client may be unable to sign and family members may not be
available. In this type of a situation, the health care provider is legally permitted to perform surgery
without consent. Consent is not informed if it is obtained from the client who is confused,
unconscious, mentally incompetent, or under the influence of sedatives.

9.A nurse is told in intershift report that a client has been appointed a legal guardian. The nurse
looks for evidence of which of the following that supports that this in fact has occurred?
a. A health care provider's prescription
b. A judicial decision in a court of law
c. Testimony of three neighbors
d. A licensed nurse's observation of bizarre behavior
Rationale: Answer B Appointment of a guardian must be done through due legal process. It
cannot be done by a health care provider's prescription. Options 3 and 4 could support the decision
that a legal guardian is necessary if the client is incompetent to make his or her own decisions, but
they are not sufficient by themselves.

10.The triage nurse identifies that a 16 year-old teenager is legally married and has signed the
consent form for treatment. What should be an appropriate action by the nurse?

A. Ask the teenager to wait until a parent or legal guardian can be contacted
B. Proceed with the triage process in the same manner as any adult client

C. Withhold treatment until telephone consent can be obtained from the partner

D. Refer the teenager to a community pediatric hospital emergency department

Rationale: Answer B -Minors may become known as an "emancipated minor" through marriage,
pregnancy, high school graduation, independent living or service in the military. Therefore, this
married client has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years
of age.

11. Which of the following is a true statement about the nurse’s role in obtaining informed consent?
A.The nurse who receives the client in the holding area of the OR is responsible for obtaining
informed consent.

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B.The nurse assigned to the client 24 hours before the surgery is responsible for obtaining informed
consent for the surgical procedure.

C.The circulating nurse is responsible for obtaining informed consent only if an outpatient surgical
procedure is performed.

D.The nurse is responsible for ensuring that informed consent has been obtained by the MD prior to
the surgical procedure.

ANSWER D- The nurse is responsible for ensuring that informed consent has been obtained
by the MD prior to the surgical procedure

12. A patient asks the nurse, “What is a Living Will?” the nurse should respond that it is a
document that:
a. Instructs a physician to withhold/withdraw life-sustaining procedures if death is near
b. Enables a person to request medication to end life in a humane and dignified manner
c. Gives consent to perform life-sustaining medical intervention during an emergency
d. Wills ones organs to help others who need a transplant to sustain life

Answer C. Living will is a legal document that an individual uses to make known his wishes to
prolong his life. It is also known as advanced directives. In this case, a living will gives consent to
perform life sustaining medical intervention to prolong life in cases of emergency. Other options
presented are incorrect because they do not describe what a living will is all about.

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 Professional Misconduct
A. The impaired professional
1. Remember that the impaired nurse is compromising client care
2. Be sure that the problem exists and can be proven
3. Communicate specific concerns to appropriate persons such as a nurse manager or
risk manager
4. Document incidents in terms of behaviors, specific times, dates - be objective
5. File a report according to the policies and procedures of the institution
B. Boundary violations
1. Definition: actions that overstep established interpersonal boundaries and meet the
needs of the nurse rather than the client.
2. Guiding principles in determining professional boundaries
a. nurse is responsible for setting and keeping boundaries
b. nurse must avoid simultaneous professional and personal relationship with a
client
c. nurse must avoid flirtation

Consequence of professional misconduct

A board of nursing must protect the public and is required to take action against the licenses of nurses who
have exhibited unsafe nursing practice

A state board of nursing may imposes penalties for professional misconduct, ranging from probation, censure,
and reprimand, to suspension or even revocation of licensure

1. A charge nurse knows that drug and alcohol use by nurses is a reason for the increasing
numbers of disciplinary cares by the Board of Nursing. The charge nurse understands that
when dealing with a nurse with such an illness, it is most important to assess the impaired
nurse to determine:

a) the magnitude of drug diversion over time

b) if falsification of clients records occurred

c) the types of illegal activities related to the abuse

d) the physiological impact of the illness on practice

1) D-- A nurse must be able to function at a level that does not affect the ability to provide
safe, quality care. The highest priority is to determine how the illness affects the nurse's
ability to practice. The other options will be addressed if an investigation is carried out

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DOCUMENTATION
Information & Documentation
o Types of patient records
 Problem-oriented medical record (POMR)
 a decision is made on the nature of the client's problem or
problems and these problems are assessed regularly
 recorded using a standardized format, by narrative notes in
the S.O.A.P. format or by flow sheets
 discharge summary relates the overall assessment of
progress during treatment and plans for follow-up care,
encouraging continuity of care
 four parts
 data base: the client's present health status
 problem list: numbered list of health problem(s)
 initial plan: plan to help overcome health problem(s)
 progress notes: all disciplines chart on the same page
 Source-oriented
 most traditional type of charting, with different disciplines
charting on separate forms
 drawback: records become very bulky, very quickly
6. Methods (styles) of charting
o Narrative charting
 the nurse records observations, data (including reactions from the client) in a
sequential and chronological order
 baseline charted every shift
 source-oriented
o S-O-A-P: problem-oriented charting; comes from a medical model
 S = subjective; what client tells you
 O = objective; what you observe, see, etc.
 A = assessment; what you think is going on based on the data
 P = plan; what you are going to do
o D-A-R
 D = data - collecting information about a problem
 A = action - the task to be completed about the problem
 R = response - the client's response to the problem
o Focus charting
 charting on an acute condition, a potential problem, a treatment or procedure,
or a client behavior
 components of this type of charting include: information about the
condition/problem, action, and client's responses
o A P-I-E charting - uses the nursing process
 A = assessment
 P = problem
 I = intervention
 E = evaluation
o Charting by exception
 uses flowsheets
 emphasis on abnormal (or what is abnormal for this particular client); normal
routine is presumed as having been done, without any problems

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7. Documentation guidelines
o General
 check that you have the correct chart
 record the facts as accurately as possible
 chart as you go
 never chart for another person
 do not mention incident reports
 avoid the use of abbreviations - when in doubt, write it out!
 all health care institutions have a list of accepted abbreviations
 refer to the Joint Commission's official "Do Not Use" list of
abbreviations
 never alter a client's record (altering a client chart is a criminal offense)
 six things that nurses must document
 assessment
 nursing diagnosis and client needs
 interventions
 care provided
 client response to care
 client's ability to manage continuing care after discharge

2. Legal guidelines for charting

o electronic health record (EHR) charting
 never share access or password with another person
 change your password frequently
 maintain confidentiality of documented information printed from the
computer
 carefully check your information before you press enter
 access information for clients under your care only
 log off when you are finished
 date and time are automatically recorded
o paper-ink
 do
 write in chronological order
 use permanent black ink
 chart the time and date for each entry
 include consent for or refusal of treatment, client responses to
interventions, calls made to other health care professionals
 write legibly
 cross through the error once, date and initial the change
 correct any errors in a timely manner
 do not
 erase, scratch out or use correction fluid (Liquid Paper or Wite
Out®)
 document for others or change documentation by others
 leave blank spaces
 recopy any charting form
 make photocopies without permission

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Information Systems and Technology

Shared Health Records – enhanced continuity of care when records from clinic/extended
care/hospital are in the same data base; ease of medical history retrieval, ease of chart access –
multiple people use same chart

Diagnositcs/procedures: results can be sent electronically to ‘experts’ in different location for

interpretation; procedures done robotically

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Documentation

1. Which of the following is a recommended guideline for safe computerized charting?

a. Passwords to the computer system should only be changed if lost.

b.Computer terminals may be left unattended during client-care activities.

c.Report accidental deletions from the computerized file to the nursing manager or supervisor.

d. Copies of printouts from computerized files should be kept on a clipboard at the nurses'
station for other nurses to access.

Rationale:
After any inadvertent deletions of permanent computerized records, the nurse should type an
explanation into the computer file with the date, time, and his or her initials. The nurse should
also contact the nursing manager or supervisor with a written explanation of the situation.
Options 1, 2, and 4 represent unsafe charting actions. Only option 3 follows the guidelines for
safe computer charting.

Test-Taking Strategy:
Use the process of elimination. Focusing on the subject of a safe guideline will direct you to
option 3. Options 1, 2, and 4 represent unsafe charting actions. Review the guidelines for
computerized documentation if you had difficulty with this question.

2. A nurse is recording an end-of-shift report for a client. What information needs to be

included?
A. As-needed medications given that shift
B. Normal vital signs that have been normal since admission
C. All of the tests and treatments the client has had since admission
D. Total number of scheduled medications that the client received on that shift

Rationale:
End-of-shift report needs to be an efficient and accurate account of the client's condition during
the last shift. It needs to include pertinent information about the client, such as tests and
treatments; as-needed medications given or therapies performed during the past 24 hours,
including the client's response to them; changes in the client's condition; scheduled tests and
treatments; current problems; and any other special concerns. The total number of medications
given or a list of all the tests and treatments that the client has had since admission are not
necessary to include. Only significant vital signs need to be included.

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3. A nurse is documenting information regarding a client's care into the computerized medical
record. Which of the following actions by the nurse would be appropriate? Select all that apply.
A. Change the password for entering computer files at least monthly.
B. Shred the printout of the nurse's flowchart at the end of the nurse's shift.
C. Use own user name and password when logging into the computer system.
D. Leave the computer terminal immediately after logging in to check on the status of a client.
E. Sign on another nurse to your account as long as the other nurse is not supplied with user name
and password.
Rationale:

Computer terminals should never be left unattended after the nurse has logged on. This could allow
unauthorized users to access the personal information of clients, and it represents a breach of
confidentiality and of the security of client records. Likewise, another user should never be allowed
access to one's account. Options 1, 2, and 3 represent actions that are acceptable ways to protect client
information.

4. Choose the correct guidelines related to narrative documentation. Select all that apply
Date and time entries.

A. Sign and title each entry.

 Use a blue-color ink pen.
 Avoid judgmental and evaluative statements.
 Document judgmental information completely.
 Do not leave blank spaces on documentation forms.

Rationale: A,B,D,E
The nurse uses a black-color ink pen to document, because black ink allows the chart to be duplicated
with adequate readability for long-term storage. The nurse always dates and times entries and signs and
titles each entry. The nurse provides objective, factual, and complete documentation and avoids
subjective, judgmental, and evaluative statements. Quotes are used to relate what the client actually
said. The nurse avoids leaving blank spaces on documentation forms, because this allows for an area in
which notes can be entered by others at a later time. The recording of information in the client's record
must be sequential.

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Incident reports must be completed for any adverse incidents

 Each agency develops a policy or protocol for reporting accidents, unusual occurrences, or
other incidents involving clients, which are not in keeping with usual agency operation.
 Incident reports are communication tools that provide information to risk managers and
administration about potential areas of exposure to liability; they may be used in legal cases
 Incident reports are used to identify problems and develop solutions to prevent same incident
from happening again
 When completing an incident report, fill out form m accurate, complete, and factual manner;
include client name and other identifying information, date/time/place of incident, facts (no
opinions or conclusions), client’s account of incident using quotation marks, witnesses, and if
applicable, equipment number or medication name and dosage
 Do not place copy in client record or make reference to incident report in client record
 Do record facts of incident in medical record

Other names for incident reports include- Variance report, Occurrence report, Adverse
Incidents and Quality Assurance Report .Information in the report must include the
following

1. Patient’s name, hospital ID number.

2. Date, time and place of incident.
3. Facts of incident. Avoid conclusions or blame. If the patient was injured. Document the
injury, the body part affected and your assessment of that body system. If patient was
not hurt, document your assessment finds to that effect.
4. Physician notification: document date and time MD was informed of incident and what
orders you received. If you did not receive any orders. document that.
5. Family notification: Document date and time you notified the family and document
name of family member you notified.
6. Identify witness to incident. The report should be completed within 24 hours. Incident
reports are not part of the medical record.
7. Identify witness to incident. The report should be completed within 24 hours. Incident
reports are not part of the medical record.

File an incident report anytime an incident occurs in which a patient, visitor, or staff
member is or could have been injured. Complete a report, too, whenever a deviation from
established policy and procedures occurs, regardless of the reason, Clearly, medication
errors, patient falls, and equipment failures are all reportable incidents. But keep in mind
that other less common events, such as a patient leaving your facility against medical advice
or the discovery that property is missing (and possibly stolen), must also be documented in
an incident report, whether or not anyone was hurt.

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1 A patient falls while getting out of bed unassisted. When completing and Incident Report, the nurse
understands that it main purpose is to:
a. Ensure that all parties have an opportunity to document what happened
b. Help establish who is responsible for the incident
c. Make available data available for quality control analysis
d. Document the incident on the patient’s chart

Answer C. Incident reports are filled out in order to record details of unusual events occurring in the
hospital and care of patients. In this case, the incident report is filled out in order to have an available
data for quality control analysis and in the future when dealing with legal liabilities. Options A, B and D
are incorrect because these are not the reason as to why nurses fill out incident reports. NEVER PUT AN
INCIDENT REPORT IN THE PATIENT’S CHAR

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Management

Problem-solving process and decision making

Involve obtaining information and using it to reach an acceptable solution to a problem

Types of managers

Frontline-Functions in role closely identified with actual delivery of care, such as charge nurse, team
leader, and client care coordinator

Middle-Roles include unit manager or supervisor with responsibilities of managing staff, preparing
budgets and schedules, and writing policies that guide client care

Nurse executive- Top-level nurse manager who may be the director of nursing services or the vice
president of client care services. Supervises multiple departments and works closely with administration
of organization

NURSES MUST PURCHASE MALPRACTICE INSURANCE

POWER

Definition : Ability to do or act; results in the achievement of desired results

Powerful Persons

 Effective nurse leaders

 Use power to improve delivery of care and to enhance the profession
 Shared power-Effective power is power that is shared by more than one individual.
Types of Power

Reward: ability to provide incentives

Coercive: ability to punish

Expert: based on having an expert knowledge base and skill level

Legitimate: based on a position in society

Personal: derived from a high degree of self-confidence

Informational: one person explains why another should behave in a certain way

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LEADERSHIP STYLES

Autocratic: leader is focused and maintains strong control, making decisions and solving all problems;
leader dominates group

****SOMETIMES REFERED TO AS AUTHORITARIAN****

*** BEST STYLE OF LEADERSHIP FOR EMERGENCIES AND DISASTER SITUATIONS***

 Leader maintains strong control Makes decisions for the group and solves all problems
 Leader commands and Motivates by coercion rather than makes suggestions
 Communication occurs down the chain of command.
 Work output by staff is usually high – good for crisis situations and bureaucratic settings.
Democratic: participatory leader has the belief that every member of the team should have input into
the development of goals and problem solving; leader is facilitator and resource person

*** ALSO CALLED PARTICIPATIVE LEADERSHIP

 Leader acts as a Facilitator and a resource person

 Includes the group when decisions are made.
 Motivates by supporting staff achievements.
 Communication occurs up and down the chain of command.
 Leader is concerned for each member of the group
 Work output by staff is usually of good quality – good when cooperation and collaboration is
necessary.
laissez-faire

a. Leader assumes a passive, nondirective. And inactive approach

b. Leadership responsibilities are either summed by the members of the group or completely
relinquished

c. All decision making is left to the group, with the leader giving little if any guidance, support, or
feedback.

d. Some unprofessional behaviors exhibited by the group may be permissible as a result of the leader’s
lack of limit setting and stated expectations

Situational- Using a combination of styles based on current circumstances and events

Leadership styles are assumed according to the needs of the group and the tasks to be achieved

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1. The nurse has recently been assigned to manage a pulmonary progressive unit at a large urban
hospital. The nurse's leadership style is participative, with the belief that all staff members assist in
decision making and the development of the unit's goals. The nurse is implementing which leadership
style?

a) democratic

b) laissez faire

c) autocratic

d) situational

1) A-- Democratic leadership is defined as participative with a focus on the belief that all members of the
group have input into the decision making process. This leader acts as a resource person and facilitator.
Laissez faire leaders assume a passive approach, with the decision making left to the group. Autocratic
leadership dominates the group, with maintenance of strong control over the group. Situational
leadership is based on the current events of the day.

2. A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns
clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership
style?

A. Autocratic

B.Situational

C.Democratic

D.Laissez-faire

Rationale: A- Autocratic leadership is an approach in which the leader retains all authority and is
primarily concerned with task accomplishment. It is an effective leadership style to implement in an
emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way
communication with the work group, and he or she makes all decisions independently. Situational
leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work
group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily
concerned with human relations and teamwork. This leadership style facilitates goal accomplishment
and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style
in which the leader gives up control and delegates all decision making to the work group.

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3. A nursing graduate is employed as a registered nurse (RN) in a local hospital. During orientation, the
nurse educator asks the RN about her understanding of the need to obtain professional liability
insurance. The appropriate response by the RN is

A."It is very expensive and not necessary."

B."The hospital's liability insurance will cover my actions."

C."Nurses are encouraged to have their own malpractice insurance."

D."The majority of suits are filed against health care providers and the hospital."

Rationale: C-Nurses need their own liability insurance for protection against malpractice lawsuits.
Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually
when a nurse is sued, the employer is also sued for the nurse's actions or inactions. Even though this is
the norm, nurses are encouraged to have their own malpractice insurance.

4. A nurse manager has identified a problem on the nursing unit and holds unit meetings for all shifts.
The nurse manager presents an analysis of the problem and proposals for actions to team members and
invites the team members to comment and provide input. Which style of leadership is the nurse
manager specifically employing?

a) situational

b) laissez-faire

c) participative

d) authoritarian

4) C-- Participative leadership demonstrates an "in-between" style, neither authoritarian nor democratic
style. In participative leadership, the manager presents an analysis of problems and proposals for
actions to team members, inviting critique and comments. The participative leader then analyzes the
comments and makes the final decision. A laissez-faire leader abdicates leadership and responsibilities,
allowing staff to work without assistance, direction, or supervision. The autocratic style of leadership is
task oriented and directive. The situational leadership style utilizes a style depending on the situation
and

5. A charge nurse observes that a staff nurse is not able to meet client needs in a reasonable time frame,
does not problem-solve situations, and does not prioritize nursing care. The charge nurse has the
responsibility to:

a) supervise the staff nurse more closely so that tasks are completed

b) ask other staff members to help the staff nurse get the work done

c) provide support and identify the underlying cause of the staff nurse's problem

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d) report the staff nurse to the supervisor so that something is done to resolve the problem

5) C-Option C empowers the charge nurse to assist the staff nurse while trying to identify and reduce the
behaviors that make it difficult for the staff nurse to function. Options A, B, and D are punitive actions,
shift the burden to other workers, and do not solve the problem.

6. When a nurse manager makes a decisions regarding the management of the nursing unit without
input from the staff, the type of leadership style that the nurse manager is demonstrating is:

a) autocratic

b) situational

c) democratic

d) laissez-faire

6) A-- The autocratic style of leadership is task oriented and directive. The leader uses his or her power
and position in an authoritarian manner to set and implement organizational goals. Decisions are made
without input from the staff. Democratic styles best empower staff toward excellence because this style
of leadership allows nurses to provide input regarding the decision-making process and an opportunity
to grow professionally. The situational leadership style utilizes a style depending on the situation and
events. The laissez-faire style allows staff to work without assistance, direction, or supervision.

7. A nurse manager is planning to implement a change in the method of the documentation system for
the nursing unit. Many problems have occurred as a result of the present documentation system, and
the nurse manager determines that a change is required. The initial step in the process of change for the
nurse manager is which of the following?

a) plan strategies to implement the change

b) set goals and priorities regarding the change process

c) identify the inefficiency that needs improvement or correction

d) identify potential solutions and strategies for the change process

7) C-- When beginning the change process, the nurse should identify and define the problem that needs
improvement or correction. This important first step can prevent many future problems, because, if the
problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is
followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the
change.

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QUALITY IMPROVEMENT

a. Quality: the degree to which client care services increase the probability of desired outcomes and
reduce the probability of undesired outcomes given the current state of knowledge
b. Performance improvement/assurance: the process of attaining a new level of performance or
quality that is superior to any previous level of performance or quality
c. Total quality management: a philosophy that emphasizes a commitment to excellence throughout
the organization

d. Six characteristics of total quality management

1. Focus on customer, i.e., client
2. Focus on outcomes
3. Total organizational involvement
4. Multi-professional approach
5. Use of quality tools and statistics for measurement
6. Identification of key areas for improvement with an emphasis on SAFETY
e. Mandated by the Joint Commission (formerly called Joint Commission on Accreditation and
Healthcare Organizations)

 Quality assurance involves an evaluation of the conditions under which care was provided,
including a(n):
o Identification of a problem
o Determination of the source and nature of the problem
o Assessment on how to effect improvement in the situation
o Designing policies for remedying the problem
o Implementation of those policies

 Quality management , on the other hand, involves quality improvement with a change in
the focus from
o Detection to prevention
o Reactive to proactive
o Correction of special causes to correction of common causes
o Problem-solving by authority to involving employees at all levels

 Almost all regulatory and voluntary accrediting agencies now require some form of
quality management
o Regulatory agency: Centers for Medicare & Medicaid Services (CMS), U.S.
Department of Health & Human Services
o Other agencies committed to quality improvement:
 The Joint Commission (read the Facts about Hospital Accreditation)
 National Committee for Quality Assurance (NCQA)
 Institute for Healthcare Improvement (IHI)
 Agency for Healthcare Research and Quality (AHRQ)
 Institute for Safe Medication Practices (ISMP)

 The focus is on improving quality of care and client safety through taking evidence-based
practices (from computer information systems to different pain management protocols)
and implementing them in various health care settings

 Standardized processes are the foundation for improvements

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 o Clinical guidelines
o Critical pathways
o Case management

 Nurses
o enable an organization to be successful in meeting standards
o facilitate collaborative practice with other health care professions to
 identify problems
 initiate change
 monitor ongoing effectiveness of care

1. A nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a
variance analysis, which of the following would indicate the need for further action and analysis?
a. A postoperative client who develops a cough and a fever
b. Clear breath sounds in a client with congestive heart failure
c. The absence of a wound infection in a client who had a coronary artery bypass graft
d. A client with diabetes mellitus demonstrating accurate use of a glucometer after teaching
Rationale: A
Variances are actual deviations or detours from the critical paths. Variances can be positive or negative,
avoidable or unavoidable, and can be caused by a variety of factors. Positive variance occurs when the
client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs
when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and
recognize negative variance early so that appropriate action can be taken. A postoperative client who
develops a cough and a fever identifies a negative outcome.

2. A nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a
variance analysis, which of the following would indicate a negative variance?

a. Signs of wound healing in a postoperative abdominal incision

b. The presence of dysrhythmias in a client with a myocardial infarction
c. Normal vital signs in a postoperative craniotomy client
d. A client demonstrating accurate insulin administration following teaching

Rationale:
Variances are actual deviations or detours from the critical paths. Variances can be positive or negative,
avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the
client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs
when untoward events prevent a timely discharge. Variance analysis occurs continually in order to
anticipate and recognize negative variance early so that appropriate action can be taken.

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3. A registered nurse is a preceptor for a new nursing graduate an is describing critical
paths and variance analysis to the new nursing graduate. The registered nurse instructs the
new nursing graduate that a variance analysis is performed on all clients:

a) continuously

b) daily during hospitalization

c) every third day of hospitalization

d) every other day of hospitalization

3) A-- Variance analysis occurs continually as the case manager and other caregivers
monitor client outcomes against critical paths. The goal of critical paths is to anticipate and
recognize negative variance early so that appropriate action can be taken. A negative
variance occurs when untoward events preclude a timely discharge and the length of stay
is longer than planned for a client on a specific critical path. Options B, C and D are
incorrect

4. A nurse manager is reviewing the critical paths of the clients on the nursing unit. The
nurse manager collaborates with each nurse assigned to the clients and performs a
variance analysis. Which of the following would indicate the need for further action and
analysis?

a) a client is performing his own colostomy care

b) purulent drainage is noted from a postoperative wound incision

c) a 1-day postoperative client has a temperature of 98.8F

d) a client newly diagnosed with diabetes mellitus is preparing his own insulin for injection

4) C -- Variances are actual deviations or detours from the critical paths. Variances can be
either positive or negative, or avoidable or unavoidable and can be caused by a variety of
things. Positive variance occurs when the client achieves maximum benefit and is
discharged earlier than anticipated. Negative variance occurs when untoward events
prevent a timely discharge. Variance analysis occurs continually in order to anticipate and
recognize negative variance early so that appropriate action can be taken. Option B is the
only option that identifies the need for further action.

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GUIDELINES TO RESTRAINTS

Restraints
Restraints are any method, chemical, physical or mechanical device, materials or equipment
attached or adjacent to the patient’s body that her or she cannot easily remove which restricts a
person’s movement, physical activity, or normal access to his or her body.

Physical restraints/safety devices require

 A signed
 Dated physician's order
 Specifying the type of restraint/safety device
And a time limit
Ordering and Using Restraints
 A physician’s prescription is needed for the use of restraints
 The prescription should state

i. The type of restraint

ii. Identify specific client behaviors for which restraints are to be used, and
iii. Identify a limited time frame for use, with start and end times specified.

 A prescription for a safety device should be renewed within a specific time in accordance with the
policy of the agency.
 The physician should never write a prescription simply stating "Restraints prn," which could be
misinterpreted to mean that the nurse may restrain the client whenever he or she deems it
necessary without checking with the physician; a nurse who receives such a prescription must
clarify it with the physician.
 In an emergency situation (e.g., when a client becomes physically abusive), a restraint may be
applied, but the nurse must contact the physician and obtain a prescription as soon

Two types of restraints defined by JCAHO are based on the purpose for the restraints

Behavioral Restraint (Almost exclusively in ER)-Used for the control of aggressive/violent behavior or behavior
that is dangerous to self or others.

Medical/Surgical Restraint (Most common on units)-Used for care management for a patient who is exhibiting
behavior that is interfering with treatment (e.g. pulling on IV, Foley, or dressings).

Types of restraints/safety devices

i. chemical - central nervous system depressants, paralytics

ii. physical - vest restraints, side rails

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 When Physical Restraints are NOT Considered to be Restraint Devices

 When used for the purposes of security, detention or public safety on patients under forensic custody (under
police guard).
 When used as a voluntary mechanical support to achieve proper body position, balance, or alignment.
 When used as a positioning or securing device to maintain position, limit mobility or temporarily immobilize a
patient during medical, diagnostic, or surgical procedures (less than 30 minutes in children).
The nurse must document three factors

iii. why restraints ARE being USED /safety devices were used
iv. how the client responded
v. whether the client needs continued restraints/safe

Other Documentation Points

 Reason for USE OF the restraint
 Alternatives to the restraints that were used
 Method of restraint
 Procedure used in applying the restraint
 Client’s response to application of the restraint
 Condition of the restrained body part
 Findings of assessment of circulatory, neurovascular, and skin integrity
 Release from the restraint with periodic movement or range-of-motion exercise
 Date and time of application of the restraint
 Findings of assessment of continued need for the restraint
 Duration of use of the restraint and client’s response on removal of the restraint
 Evaluation of the client’s response

****The reason for the safety device should be given to the client and the family, and their
permission should be sought. *****

Use a half-bow or safety knot (quick release tie) to secure the device to the bed frame or chair,
not to the side rails. ****NEVER ATTACH RESTRAINTS TO SIDE RAILS ****

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Situations for Temporary Use of Restraints

•When less restrictive measures are not successful

•To ensure the physical safety of the client and reduce the risk of injury (e.g., in falls)

•Reduce the risk of injury to others by the client who engages in disruptive or agitated behavior

•Prevent the confused or combative client from interrupting therapy (e.g., pulling

 Laws and accreditation guidelines

o The Omnibus Budget Reconciliation Act (1997) states that freedom of restraints is a
right by all clients across care settings
o The Social Security Act states: "Free from restraints is the right to be free from physical
or mental abuse, corporal punishment, involuntary seclusion, and any physical or
chemical restraints imposed for purposes of discipline or convenience and not required
to treat the resident's medical symptoms."

Q. Is the one hour face-to-face assessment still required if a patient is placed in restraints or
seclusion for violent or self-destructive behavior?

A. Yes, in the Comprehensive Accreditation Manual for Hospitals, the one hour face-to-face
assessment by a physician or licensed independent practitioner responsible for the care of
the patient is required. The physician or licensed independent practitioner evaluates the
patient in person within one hour of the initiation of the restraints. A registered nurse or a
physician assistant may conduct the in-person evaluation within one hour of the initiation
of restraint or seclusion if this person is trained in accordance with requirements in
Standard PC.03.05.17, EP3. If the one hour face to face evaluation is completed by a trained
nurse or trained physician assistant, he or she would consult with the attending physician
or other licensed independent practitioner responsible for the care of the patient after the
evaluation, as determined by hospital policy. (PC.03.05.11 EP2)Some states may have
statue or regulation requirements that are more restrictive than the requirements in this
standard.

A restraint does not include devices, such as orthopedically prescribed devices, surgical
dressings or bandages, protective helmets, or other methods that involve the physical
holding of a patient for the purpose of conducting routine

PHYSICIAN’S ORDER CRITERIA FOR BEHAVIORAL RESTRAINTS

1. Physicians or licensed independent practitioners (LIP) are required to see and evaluate the need
for a behavioral restraint or seclusion within 1-hour of the initiation of the intervention.
Physician must conduct a face-to-face assessment with counter signed orders within ONE
hour.
2. Order must include:
 Start and stop time
 Date

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  Reason for restraint
 Type of restraint used
 Signature of Physician
Time Frames for Renewals

Maximum duration 4 hours ages adults 18 and older

2 hours ages 9-17 years old
1 hour 0-8 year old

Organizations must develop their own guidelines for time limits on orders that use restraints for
other than violent and self-destructive behavior. Patient safety, patient assessment, and the type of
restraint used will determine the guideline for the time limit for a restraint that is used for non-
violent, non- self destructive behavior.

PHYSICIAN’S ORDER CRITERIA FOR MEDICAL RESTRAINTS

Physicians or licensed independent practitioners (LIP) are required to see and evaluate the
need for a medical restraint within 24 hours of the initiation of the intervention. Physician
must make face-to-face evaluation within 24 hours of initiation of restraints and sign
order.

Order must include:

 Start and stop time
 Date
 Reason for restraint
 Type of restraint used
 Signature of Physician

Restraint orders must be updated according to policy (commonly every 24 to 48

hours)

Health care providers can legally restrain a client under certain conditions defined by the
law and by the health care facility's policies and procedures

 Use of restraints must be accompanied by the health care provider's orders, except in
an emergency
 There can be no "standing orders" or "PRN" orders for restraints
o The least restrictive type of restrain must be used first
o Training about restraints is required for all staff who have direct contact with clients
o There must be documentation of attempts at restraint alternatives

General guidelines when restraints are used

o The client must be closely monitored when restrained

o Restraints should be released periodically and the skin integrity of the area checked for
breakdown

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o Document all pertinent details, including why the restraint is being used and the client's
response
 Remember that death can result from improper use of restraints

AGAIN Restraints are a LAST RESORT -Use Restraints only when:

 You have exhausted all alternative interventions

 Vital treatments depend on their use
 There is a clear and present danger
IF RESTRAINTS MUST BE USED

 Protect the patient’s rights and dignity

 Choose the least restrictive method
 Document each occurrence of restraint use
 Only properly trained and authorized staff may apply and remove restraints
 Choose the correct restraint size - if too small, restraints may cause increased agitation and if
too large, the patient can slide down in the restraint which could lead to asphyxiation.
The following policies apply to the use of restraints:

 Physician orders cannot be written as “standing” or “prn”.

 Restraints will not be used for the convenience of the staff.
 The use of restraints will only be used to prevent the patient from harming themselves or
others or when the patient is interfering with treatment.
Types of Restraints
Belt Restraint

 This belt like device, which is wrapped around the client’s waist, is used to secure a client to bed or
stretcher.
 Ensure that the device is not secured too tightly across the chest or abdomen.
 Tie the belt to the bed frame or hook it under the bed, rather than to the side rails, to prevent injury
when the side rail is raised or lowered.

Extremity (Wrist or Ankle) Restraint

 This device is wrapped around the wrist or ankle to immobilize the extremity.
 Extremity restraints are used to protect the client from a fall or to keep him or her from pulling

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 at or removing a tube or other equipment.
 The soft part of the device is placed against the skin before the restraint is secured in place.

Mitten Restraint

 This device, resembling a thumbless mitten, is placed over the hand.

 In addition to serving as a covering for the hand, the mitten restraint prevents the client from
pulling on equipment, removing dressings, or scratching him- or herself.
 The mitten restraint allows a greater degree of movement than does a wrist restraint.

Elbow Restraint

 This device consists of a fabric arm wrap with slots into which tongue blades are inserted.
 The elbow restraint is used in children to prevent flexion of the joint.
 The device may be used when an intravenous line is in place.

Mummy Restraint

 This device is used to restrain an infant or small child during examination or treatment of the
head or neck.
 A blanket or sheet may be used to fashion a mummy restraint.
 Some types of mummy restraints secure the child to a board with an attached Velcro device.

Complications of Restraints

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 •Entanglement, which may result in asphyxiation or strangulation

•Pressure ulcers

•Constipation

•Respiratory infections

•Urinary and fecal incontinence

•Contractures

•Nerve damage

•Circulatory impairment

•Humiliation or loss of self-esteem

•Fear

•Anger

Alternatives to Using Restraints

 Maintain orientation of the client to his or her surroundings.
 Explain procedures and treatments to the client and family to help alleviate anxiety.
 Encourage a family member or friend to stay with the client; use agency personnel (e.g., a sitter)
for clients who need supervision.
 Evaluate all medications that the client is taking; some can cause altered mental status and
adverse behavior.
 Limit environmental stimuli for the client who is confused or agitated.
 Assign confused or disoriented clients to rooms near the nurses’ station so that they may be
monitored closely.
 Provide appropriate visual and auditory stimuli (e.g., clocks, calendars, television, radio, familiar
objects such as family pictures) to the client.
 Maintain toileting routines to help prevent restlessness.
 Use relaxation techniques with the client.
 Exercise and ambulate the client as the client's condition allows.
 If possible, avoid treatments and procedures that will agitate the client .

Legal and Ethical Guidelines For Restraints

 Federal, state, and agency policy and procedures regarding the use of restraints and safety devices
must be followed; the application of restraints in violation of such regulations constitutes abuse.
 A restraint should be used only to ensure the physical safety of the client or other clients and only
when other measures have failed to ensure the safety of the client and other clients.
 Safety devices should not interfere with any treatment or exacerbate the client’s health problem.
 The client is assessed to determine the appropriateness of the type of restraint or safety device that
is to be used.
 The least restrictive type of restraint should be used.
 The reason for use of the safety device should be given to the client and the family, and their
permission should be sought; informed consent may be required.

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  Side rails used to restrict a client’s mobility may be considered a restraint.
 Alternative safety devices such as the Ambularm should be used whenever possible.

Restraint Alternatives Devices That Allow Free Movement

Ambularm Device

 This device, worn on the leg, signals when the leg is moved into a dependent position.
 The Ambularm is used for clients at risk for falling who climb out of bed.
 Devices that may be attached to a bed or chair or to the client's mattress or nightgown are also
available.

Alarmed Armband

 This device, worn by the client, signals when the client wanders outside the safe confines of the
nursing facility.

Alternatives to Using Restraints

 Maintain orientation of the client to his or her surroundings.
 Explain procedures and treatments to the client and family to help alleviate anxiety.
 Encourage a family member or friend to stay with the client; use agency personnel (e.g., a sitter)
for clients who need supervision.
 Evaluate all medications that the client is taking; some can cause altered mental status and
adverse behavior.
 Limit environmental stimuli for the client who is confused or agitated.
 Assign confused or disoriented clients to rooms near the nurses’ station so that they may be
monitored closely.
 Provide appropriate visual and auditory stimuli (e.g., clocks, calendars, television, radio, familiar
objects such as family pictures) to the client.
 Maintain toileting routines to help prevent restlessness.
 Use relaxation techniques with the client.
 Exercise and ambulate the client as the client's condition allows.
 If possible, avoid treatments and procedures that will agitate the client.

The Nurse’s Responsibilities

 The nurse should review the manufacturer’s instructions regarding application of a restraint;
incorrect application could result in client injury or death.
 Inspect the area where the restraint is to be applied to ensure that tubes or other treatment
devices will not be affected by the restraint and to confirm skin integrity.
 Place the client in the proper body alignment and pad the skin and bony prominences before
applying the restraint.
 Once the restraint has been applied, attach it to the bed frame, not the side rails; ensure that a
bed’s wheels are locked and that the bed’s height has been adjusted to its lowest position.
 Use a quick-release tie (half-bow or safety knot) to secure the device to the bed frame or chair
(allows quick release).
 Ensure that there is enough slack on the straps to allow some movement of the restrained body

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 part.
 Ensure that the call bell is within the client's reach.
 To prevent obstruction of circulation, ensure that two fingers can be inserted under the secured
restraint.
 Assess skin integrity and neurovascular and circulatory status every 30 minutes.
 Remove the restraint every 2 hours for 30 minutes to permit muscle exercise, perform range-of-
motion exercises, and promote circulation; remain with client during this time. (If the client is
agitated or has a tendency to become violent, remove one restraint at a time.)
 Continually assess the need for restraint and provide documentation regarding the restraint.
 Monitor and evaluate the client’s response to the restraint/safety device.

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SUMMARY PRIORITY POINTS TO REMEMBER

 Restraints are devices used to restrict client movement.

 Federal, state, and agency policy and procedures regarding the use of restraints and other safety devices
must be followed; the application of restraints in violation of these regulations constitutes abuse.
 Side rails used to restrict a client’s mobility may be considered a type of restraint.
 A physician’s prescription, including the duration and circumstances under which the restraints are to be
used, is required.
 A restraint should be used only to ensure the physical safety of the client or other clients and only when
other measures have failed to ensure safety.
 The least restrictive type of restraint should be used.
 Skin integrity and neurovascular and circulatory status must assessed every 30 minutes in a client who is
being physically restrained.
 The restraint is removed every 2 hours for 30 minutes to permit muscle movement, range-of-motion
exercise, and promotion of circulation.
 Continually assess the need for restraints and provide documentation with regard to the restraint.

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1. A nurse is giving a report to a nursing assistant who will be caring for a client who has
hand restraints. The nurse instructs the nursing assistant to assess the skin integrity of the
restrained hands every:

a) 2 hours

b) 3 hours

c) 4 hours

d) 30 minutes

ANSWER) D -- The nurse should instruct the nursing assistant to assess restraints and
skin integrity every 30 minutes. Agency guidelines regarding the use of restraints should
always be followed.

2. A physician has written an order for a vest restraint to be applied on a client from 10:00
pm to 7:00 am because the client becomes disoriented during the night and is at risk for
falls. At 11:00 pm, the charge nurse makes rounds on all of the clients with the vest
restraint, which observation by the charge nurse would indicate that the nurse who cared
for this client performed an unsafe action in the use of the restraint?

a) a safety knot was used to secure the restraint

b) the client's record indicates that the restraint will be released every 2 hours

c) the restraint was applied tightly

d) the call light was placed within reach of the client

ANSWER C-- Restraints should never be applied tightly because that could impair
circulation. The restraint should be applied securely (not tightly) to prevent the client from
slipping through the restraint and endangering himself or herself. A safety knot should be
used because it can easily be released in an emergency. Restraints, especially limb
restraints, must be released every 2 hours (or per agency policy) to inspect the skin for
abnormalities. The call light must always be within the client’s reach in case the client
needs assistance

3. A nurse manager is reviewing with the nursing staff the purposes for applying wrist and
ankle restraints (security devices) to a client. The nurse manager determines that further
review is necessary when a nursing staff member states that an indication for the use of a
restraint is to:

a) limit movement of a limb

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b) keep the client in bed at night

c) prevent the violent client from injuring self and others

d) prevent the client from pulling out intravenous lines and catheters

ANSWER) B-- Wrist and ankle restraints are devices used to limit the client's movement in
situations when it is necessary to immobilize a limb. They are applied to prevent the client
from injuring self or others; from pulling out intravenous lines, catheters, or tubes; or from
removing dressings. Restraints also may be used to keep children still and from injuring
themselves during treatments and diagnostic procedures. Restraints are not applied to
keep a client in bed at night and should never be used as a form of punishment.

4. When assessing the client with the vest restraint (security device) at the beginning of day shift,
which observation by the charge nurse would indicate that the nurse who placed the vest restraint
on the client failed to follow safety guidelines?

a) a hitch was used to secure the restraint

b) the call light was placed within reach of the client

c) the restraint was applied tightly across the client's chest

d) the client's record indicates that the restraint will be released every 2 hours

4) C-- A vest restraint should never be applied tightly because it could impair respirations. A
hitch knot may be used on the client because it can easily be released in an emergency. The
call light must always be within the client's reach in case the client needs assistance. The
restraint needs to be released every 2 hours (or per agency policy) to provide movement.

5. An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child
with a cleft palate repair are:

A. Elbow restraints

B. Full arm restraints

C. Wrist restraints

D. Mummy restraints

Rationale. A. The least restrictive restraint for the infant with cleft lip and cleft palate repair is
elbow restraints. Answers B, C, and D are more restrictive and unnecessary; therefore, they are
incorrect.

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5. Which of the following statements is an OBRA regulation that the nurse must keep in
mind when considering applying a restraint to a client?

A. Apply physical restraints as a first-choice intervention in fall prevention.

B. The physician's order for restraints must be time limited.

C. Verbal or telephone orders for restraints must be signed within 72 hours.

D. Restraints cannot be applied if a family member objects.

Correct Answer: B- The physician's order for restraints must be time limited. OBRA clearly states
that restraints should be applied only as a last resort. Regulations also require that restraints be
applied only under a physician's order, and it must specify why the restraint is used and for how
long it will be used. The nurse should not be influenced by a family member's advice not to restrain
the client.

6. When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do
which of the following things? [Hint]

A. Tie the straps to the side rails.

B. Tie the straps to the movable part of the bed frame.

C. Tie the straps with a square knot.

D. Tie the straps with a quick-release knot.

Correct Answer: D Tie the straps with a quick-release knot. The straps or ties of the vest
restraint are to be tied to the immovable part of the bed frame. The straps are tied with a
quick-release knot (half-bow knot).

7. The nurse finds that an assigned client is restless, agitated, and confused and is thinking of
restraining the client. Which of the following questions is most important for the nurse to
ask?

A. "Which restraint is most appropriate?"

B. "Will I be able to get an order for a restraint?"

C. "What is the underlying cause of the restless, agitated, confused behavior?"

D. "Could I try some medication to relax the client prior to using restraints?"

Correct Answer: C "What is the underlying cause of the restless, agitated, confused behavior?"
When determining the need for a restraint, always assess the underlying reason for a client's
restlessness, agitation, or confusion

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8. The nurse assesses a cyanotic appearance and cool temperature in the hand of a client
wearing a wrist restraint. The client complains of numbness and tingling in the hand.
What should the nurse do first?
A. Remove the restraint and call the physician.

B. Reapply the restraint in a different area of the wrist.

C. Leave the restraint in place and notify the physician.

D. Loosen the restraint and exercise the limb.

Correct Answer: D Loosen the restraint and exercise the limb

9. A nurse applies restraints to a client who is combative. The nurse informs the physician
and knows that the physician must see the client within what time frame for evaluation?

A.1 hour

B. 4 hours

C.12 hours

D. 24 hours

Correct Answer: 1 hour

10. Physical restraints are being used to keep a client from climbing out of bed. Which of the
following are true statements re: restraints?

A. Restraints can be ordered prn.

B. The MD order for restraints stands for the remainder of the time the client is in the hospital. No
further orders are needed.

C. Skin integrity and neurovascular checks should be performed every 30 minutes while the
restraint is in place.

D. Restraints should be removed every four hours as the client is assisted to perform ROM
exercises.

ANSWER C. Skin integrity and neurovascular checks should be performed every 30 minutes while
the restraint is in place

A. Restraints can be ordered prn. NEVER! Must include type, client behavior that mandates,
time frame for use. B. The MD order for restraints stands for the remainder of the time the
client is in the hospital. No further orders are needed. NO -Order must be renewed within a
specified time frame. D. Restraints should be removed every four hours as the client is
assisted to perform ROM exercises. NO -Every two hours.

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 Nursing Care Delivery Systems
A. Functional nursing (task nursing)
1. Needs of clients are broken down into tasks
2. Tasks are assigned to various levels of health care workers according to licensure
and skill
3. Example: RN gives medications and UAP give bed baths for one group of clients
4. Tasks are delegated by the charge nurse
5. Team members focus on delegated tasks and this results in fragmentation of care
and lack accountability by the team member
B. Team nursing
1. Most common nursing care delivery system
2. A team of nursing personnel provides total care to a group of clients
3. Team leaders supervise client care teams, which usually consist of an RN, LPN, and
UAP
4. Team leader reviews the client's plan of care and progress with team members
during team conference
5. Team usually lead by the Registered Nurse
6. Team leader determines staff assignments
7. Each staff member is accountable for client care and outcomes
8. Modular nursing is similar to team nursing
C. Total client care (case method)
1. An RN is responsible for all aspects of care of one or more clients
2. The LPN may be assigned to assist the RN
3. Currently, this type of care is provided in areas requiring high level of nursing
expertise, such as the critical care unit (CCU) or the post-anesthesia recovery unit
(PACU)
D. Relationship based practice or Primary nursing

This style of nursing is concerned about keeping the nurse at the bedside,actively involved in client care.

1. The RN maintains a client load of primary clients

2. The primary nurse designs, implements and is accountable for the nursing care of
those clients during their entire stay on the unit
a. has the benefit of continuity of care but may not be feasible with varying
schedules
b. has been found to result in greater nurse satisfaction, more personalized
care, less turn over, and fewer negative outcomes for patients
E. Practice partnerships
1. An RN and an assistant (UAP, LPN, less-experienced RN, graduate nurse, or nurse
intern) agree to be practice partners
2. Partners work together on same schedule with same group of clients
3. Senior partner directs the work of the junior partner within the scope of each partner's
practice

Remember the steps in the Nursing Process - A D elicious PIE

A =Assessment
D =Diagnosis
P =Planning
I = Implementation
E =Evaluation

F. Case management

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 1. Model for identifying, coordinating, and monitoring the implementation of services needed to
achieve desired client outcomes within a specified period of time
2. Organizes client care by major diagnosis or Diagnosis Related Group (DRG)
3. A collaborative health care team defines the expected outcomes of care and care strategies
for a client population by defining critical paths
4. A registered nurse manager is assigned to coordinate, communicate, collaborate, problem
solve, facilitate and evaluate client care for a group of clients
5. Case manager usually does not provide direct client care but coordinates care provided by
licensed and unlicensed nursing personnel according to a critical path
6. Critical pathways are plans for providing care to the client and family
a. identify desired outcomes
b. state expected amount of time and resources to be used
c. focus on specific diagnoses or procedures that are high volume and or high resource
use (and therefore costly)
d. promote collaboration among disciplines (health care professionals)
7. The essential components of case management include
a. collaboration of all health care team members
b. identification of expected patient outcomes with time frames
c. use of principles of continuous quality improvement (CQI) and variance analysis
d. promotion of professional practice
8. Client involvement and participation is key to successful case management

The Case Management Resource Guide is a free, searchable

database of health care services, facilities, businesses and
organizations.

Refer to the University of Texas Medical Branch Web site for

examples of clinical practice guidelines, critical pathways and
primary care guidelines.

G. Differentiated practice
1. Identifies distinct levels of nursing practice based on defined abilities that are incorporated into job
descriptions
2. Structures nursing roles according to education, experience, and competency
H. Client-centered care
1. The RN coordinates a team of multi-functional unit-based caregivers
2. All client care services are unit-based, including admission, discharge, diagnostic testing and support
services
3. Uses UAPs to perform delegated client care tasks

1. A licensed practical nurse is attending an agency orientation meeting about the nursing
model of practice implemented in the facility. The nurse is told that the nursing model is a
team nursing approach. The nurse understands that which of the following is a
characteristic of this type of nursing model of practice

A. A task approach method is used to provide care to clients.

B. Managed care concepts and tools are used when providing client care.

C. Nursing staff are led by a nurse when providing care to a group of clients.

D.A single registered nurse is responsible for providing nursing care to a group of clients.

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Rationale: B

In team nursing, nursing personnel are led by a nurse when providing care to a group of
clients. Option 1 identifies functional nursing. Option 2 identifies a component of case
management. Option 4 identifies primary nursing.

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2. A new nursing graduate is attending an agency orientation regarding the nursing model of
practice implemented in the health care facility. The nurse is told that the nursing model is a
team nursing approach. The nurse understands that planning care delivery will be based on
which characteristic of this type of nursing model of practice?

a) a task approach method is used to provide care to clients

b) managed care concepts and tools are used in providing client care

c) an RN leads nursing personnel in providing care to a group of clients

d) a single RN is responsible for providing nursing care to a group of clients

2) C-- In team nursing, nursing personnel are led by a registered nurse leader in providing
care to a group of clients. Option A identifies functional nursing. Option B identifies a
component of case management. Option D identifies primary nursing.

3. The nurse manager is planning to implement a change in the nursing unit from team
nursing to primary nursing. The nurse anticipates that there will be resistance to the change
during the change process. The primary technique that the nurse would use in implementing
this change is which of the following?

a) introduce the change gradually

b) confront the individuals involved in the change process

c) use coercion to implement the change

d) manipulate the participants in the change process

3) A -- The primary technique that can used to handle resistance to change during the change
process is to introduce the change gradually. Confrontation is an important strategy used to
meet resistance when it occurs. Coercion is another strategy that can be used to decrease
resistance to change but is not always a successful technique for managing resistance.
Manipulation usually involves a covert action, such as leaving out pieces of vital information
that the participants might receive negatively. It is not the best method of implementing a
change.

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4. A nursing instructor asks the nursing student to describe the definition of a critical path.
Which of the following statements, if made by the student, indicates a need for further
understanding regarding critical paths?

a) they are developed through the collaborative efforts of all members of the health care team

b) they provide an effective way of monitoring care and for reducing or controlling the length of
hospital stay for the client

c) they are developed based on appropriate standards of care

d) they are nursing care plans and use the steps of the nursing process

4) D-- Use the process of elimination and knowledge regarding the definition and purpose of
critical paths to direct you to option D. Note the strategic words in the question, a need for
further understanding. These words indicate a negative event query and ask you to select an
option that is incorrect. If you had difficulty with this question, review critical paths.

5. During orientation, a graduate nurse learns that the nursing model of practice
implemented in the facility is a primary nursing approach. When the nurse attends report on
the medical unit, the nurse will verify with the staff which of the following characteristics of
primary nursing?

a) critical paths are used when providing client care

b) the nurse manager assigns tasks to the staff members

c) a registered nurse (RN) leads nursing staff in providing care to a group of clients

d) a single RN is responsible for planning and providing individualized nursing care to clients

5) D-- Primary nursing is concerned with keeping the nurse at the bedside actively involved
in direct care while planning goal-directed, individualized client care. Option A identifies a
component of case management. Option B identifies functional nursing. Option C identifies
team nursing.

6. A clinical nurse manager conducts an inservice educational session for the staff nurses
about case management. The clinical nurse manager determines that a review of the
material needs to be done if a staff nurse stated that case management:

a) manages client care by managing the client care environment

b) maximizes hospital revenues while providing for optimal client care

c) is designed to promote appropriate use of hospital personnel and material resources

d) represents a primary health prevention focus managed by a single case manager

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6) D-- Case management represents an interdisciplinary health care delivery system to
promote appropriate use of hospital personnel and material resources to maximize hospital
revenues while providing for optimal client care. It manages client care by managing the
client care environment.

7.A nurse asks a nursing student to describe case management. Which response by the
student indicates a lack of understanding about this concept?

a."It represents a primary health prevention focus managed by a single case manager."

b."It is managing client care by managing the client care environment."

c."It is designed to promote appropriate use of hospital personnel and material resources."

d."It maximizes hospital revenues while providing for optimal outcome of client care."

Rationale:

Case management represents an interdisciplinary health care delivery system to promote

appropriate use of hospital personnel and material resources to maximize hospital revenues
while providing for optimal outcome of care. Options 2, 3, and 4 identify the components of
managed case

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HEALTH CARE TEAM COLLABORATION

Client care planning can be accomplished through referrals to or consultations or

collaborations with other health care specialists and through client e conferences, which
involve members from all health care disciplines. This approach helps ensure lontinuity of
care.

REPORTS

4. Reports should be Factual, Accurate, Current. Complete, and Organized.

5. Reports should include essential background information, subjective data, objective data, any
changes in the client’s status, nursing diagnoses. Treatments and procedures, medication
administration, client teaching, discharge planning. Family information, the client’s response to
treatments and procedures, and the client’s priority needs.
CHANGE OF SHIFT

1. Report maybe written, oral audiotaped or provided during walking rounds at the bedside
2. The report describes the client’s health status and informs the nurse on the next shift about
the client’s needs and priorities for care.
TELEPHONE REPORTS

Purposes include informing a physician of a client’s change in status, communicating information

about a client’s transfer to or from another unit or facility, and obtaining results of laboratory or
diagnostic tests.

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Communication skills and conflict resolution

o Communication
 involves perception to receive a message
 involves expectation - the unexpected may be ignored
 makes demands on nurses to think and respond
 is different than information
o Types of communication
 downward - used to relate organizational policy such as position
description and rules and regulations
 upward - include such things as staff meetings
 lateral - between staff members, i.e. to coordinate activities
 diagonal - staff from different levels work together on a project
o Causes of conflict
 inadequate communication
 incorrect facts
 unstable leadership or inadequate action plans
 misunderstood roles or responsibilities
 receiving directions from two or more delegators
 lack of or limited staff input into decisions
 inability to accept change
 power issues
o Prevention of conflict includes
 allocating resources fairly
 avoiding unexplained changes
 clearly stating expectations
 addressing staff fears
o Dealing with conflict
 take prompt action
 help parties resolve conflict among themselves (communicate trust
that parties can accomplish resolution)
 maintain an objective approach
 avoid criticism
 use problem solving approach
 provide privacy for sensitive issues
 negotiate for agreements- not winning or losing
 focus on patient care interests
 avoid emotional outbursts
 include a third party when mediation seems the best choice

7. Communication and collaboration techniques

o SBAR technique - provides a standardized framework for communication between
members of the health care team
 S = situation (a concise statement of the problem)
 B = background (pertinent and brief information related to the situation)
 A = assessment (analysis and considerations of options - what you
found/think)
 R = recommendation (action requested/recommended - what you want)
o "I PASS the BATON" - used to improve "handoffs" and transitions in health care, with
opportunities to ask questions, clarify, and confirm
 I = introduction (introduce yourself and your role/job)
 P = patient (name, identifiers, age, gender, location)

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  A = assessment (presenting chief complaint, vital signs and symptoms and
diagnosis)
 S = situation (current status/circumstances, including code status, recent
changes, response to treatment)
 S = safety concerns (critical lab values/reports, socio-economic factors,
allergies, alerts such as falls, isolation, etc.)
 B = background (co-morbidities, previous episodes, current medications,
family history)
 A = actions (what actions were taken or are required and provide brief
rationale)
 T = timing (level of urgency and explicit timing, prioritization of actions)
 O = ownership (who is responsible - nurse/doctor/team and patient/family
responsibilities)
 N = next (what will happen next? anticipated change? what is the PLAN?
what is the contingency plan?)
o CUS - a process used to more effectively advocate for clients when there is a
concern
 C = concern ("I am concerned...")
 U = uncomfortable ("I am uncomfortable...")
 S = safety ("this is unsafe...")

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COMMUNICATION PRACTICE QUESTIONS

1. A charge nurse is supervising a new registered nurse (RN) who is providing care to a client
with end-stage heart failure. The client is withdrawn and reluctant to talk, and she shows
little interest in participating in hygienic care or activities. Which statement, if made by the
new RN to the client, indicates that the new RN requires further teaching regarding the use
of therapeutic communication techniques?

a) what are your feelings right now?

b) why don't you feel like getting up for your bath?

c) these dreams you mentioned, what are they like?

d) many clients with end-stage heart failure fear death

1) B-- When the nurse asks a "why" question of the client, the nurse is requesting an
explanation for feelings and behaviors when the client may not know the reason. Requesting
an explanation is a nontherapeutic communication technique. In option A, the nurse is
encouraging the verbalization of emotions or feelings, which is a therapeutic communication
technique. In option C, the nurse is using the therapeutic communication technique of
exploring, which involves asking the client to describe something in more detail or to
discuss it more fully. In option D, the nurse is using the therapeutic communication
technique of giving information. Identifying the common fear of death among clients with
end-stage heart failure may encourage the client to voice con

2. A nurse is observing a nursing assistant talking to a client who is hearing impaired. The
nurse would intervene if which of the following is performed by the nursing assistant during
communication with the client?

a) the nursing assistant is speaking in a normal tone

b) the nursing assistant is speaking clearly to the client

c) the nursing assistant is facing the client when speaking

d) the nursing assistant is speaking directly into the impaired ear

2) D-- When communicating with a hearing-impaired client, the nurse should speak in a
normal tone to the client and should not shout. The nurse should talk directly to the client
while facing the client, and he or she should speak clearly. If the client does not seem to
understand what is being said, the nurse should express the statement differently. Moving
closer to the client and toward the better ear may facilitate communication, but the nurse
needs to avoid talking directly into the impaired e

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3. A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a
client with end-stage heart failure. The client is withdrawn, reluctant to talk, and shows little
interest in participating in hygienic care or activities. Which statement by the LPN to the
client indicates that the LPN needs instructions in the use of therapeutic communication
skills?

a) you are very quiet today

b) what are your feelings right now?

c) why don't you feel like getting up?

d) tell me more about your difficulty with sleeping at night

3) C -- When a "why" question is made to the client, an explanation for feelings and behaviors is
requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic
communication technique. In option A, the LPN is using the therapeutic communication technique
of acknowledging the client's behavior. In option B, the LPN is encouraging identification of
emotions or feelings. In option D, the LPN is using the therapeutic communication technique of
exploring, which is asking the client to describe something in more detail or to discuss it more fully.

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Test I - Foundation of Nursing, Nursing Research, Professional Adjustment, Leadership

and Management

1.A nurse has just received a unit of packed red blood cells from the blood bank to transfuse
into a client as ordered. Before, preparing the blood for transfusion the nurse noticed the
presence of bubbles in the bag. The nurse should take which of the following actions?

a. The nurse must look for another registered nurse to double check the bag

b. The nurse must add 10ml of normal saline to the bag to remove the bubbles

c. The nurse must return the bag to the blood bank for replacement

d. The nurse must add 100 units of Heparin to the bag

2.A nurse is assisting the physician in inserting a chest tube to the client. The nurse selects
which of the following materials to be used as the first layer of the dressing at the chest tube
insertion site?

a. The nurse must prepare a 4x4 sterile gauze

b. The nurse must put absorbent kelix dressing

c. Petrolatum jelly gauze

d. Gauze with betadine

3.A physician orders 1L of ½ normal saline to infuse over 8hours. The drop factors is 15
drops per 1ml. A nurse prepares to set the flow rate at how many drops per minute?

a. 20 gtts/minute

b. 28 drops per minute

c. 31 gtts/minute

d. 22 drops per minute

4.A nurse enters a client’s room to perform physical assessment. The nurse wants to test the
reflexes of the client. The nurse does which of the following as the most appropriate nursing
action?

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a. Use a penlight to shine a light towards the bridge of the nose

b. Stimulate the back of the throat using a tongue depressor

c. Pull down the client’s lower eyelids

d. Ask the client to swallow

5.Mr. Cruz, 40 year old client was diagnosed with chronic pancreatitis. The nurse checks the
laboratory results, anticipating a laboratory report that indicates a serum amylase level of:

a. 100 units/L

b. 500 units/L

c. 45 units/L

d. 300 units/L

6. At 8:00 AM a nurse is preparing to change the Total Parenteral Nutrition (TPN)

solution bag and tubing. The client’s central venous line is located in the right subclavian
vein. The nurse would instruct the client to do which of the following most essential items
during the tubing change?

a. instruct the client to breathe normally

b. the nurse must turn the head of the client to the right

c. ask the client to take a deep breath, hold it, bear down

d. tell the client to exhale slowly and evenly until tubing change is done

7. A client begins to exhibit atrial fibrillation and has a ventricular rate at 150 beats per
minute. The nurse assess the client for:

a. nausea and vomiting

b. flat neck veins

c. hypotension and dizziness

d. hypertension and headache

8. A nurse is making initial rounds at the beginning of the shift. She enters the room of a
client receiving total parenteral nutrition (TPN) and discovers that the bag is empty. Which

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of the following solutions readily available on the nursing unit should the nurse hang until
another TPN solution is mixed and delivered to the nursing unit?

a. 10% dextrose in water

b. 5% dextrose in water

c. 5% dextrose in 0.9% sodium chloride

d. NOTA

9. A physician tells a nurse that the client’s intravenous line will be discontinued. A nurse
obtains which of the following supplies from the unit supply area for use in applying
pressure to the site after removing the intravenous (IV) catheter?

a. Sterile gauze

b. Adhesive bandage

c. Betadine swab

d. Alcohol swab

10. A physician’s order reads Potassium chloride 30mEq to be added to 1L ml normal saline
and to be given over 10-hour period. The available potassium chloride is 40mEq per 20ml. A
nurse prepares how many milliliters of Potassium Chloride to administer the correct dose of
medication?

a. 15ml

b. 10ml

c. 50ml

d. 20ml

11. A nurse is assisting a physician performing a liver biopsy. A nurse places the client in which of
the following most appropriate position following the procedure?

a. Supine

b .Prone

c. At right side-lying position with a small pillow or folded towel under the puncture site

d.At the left side-lying position with a small pillow or folded towel under the puncture site

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12.An anxious client comes to the Emergency Department with chief complaint of pain on
the left side of his chest. A chest X-ray examination reveals a left pneumothorax. When
assessing the left side of the client’s chest, the nurse would expect to find:

a. a vocal fremitus on palpation

b. a dull sound on percussion

c. an absence of breath sounds on auscultation

d. rales and rhonchi on auscultation

13.A nurse is inserting an indwelling urinary catheter into a male client. The client
complains of pain as the nurse inflates the balloon with a syringe. The nurse does which of
the following:

a. aspirates the fluid from the balloon, advances the catheter farther then reinflates the balloon

b. removes the syringe from the balloon because discomfort is normal and temporary

c. aspirates the fluid from the balloon, waits until the discomfort subsides, then reinflates the
balloon

d. aspirates the fluid from the balloon, removes the catheter, reinsert a new catheter

14. A female client is admitted to the hospital, before performing a venipuncture to the client
to initiate continuous intravenous (IV) therapy, a nurse should :

a. place a cool compress over the vein

b. Apply a tourniquet below the chosen vein site

c. Inspect the IV solution for particles or contamination

d. Secure an arm board to the joint located above the IV site

15. A client comes to the clinic for a check up and suspected of having Tuberculosis. The
nurse understands the most accurate method for confirming the diagnosis is:

a. obtaining client’s health history

b. a positive Purified Protein Derivative Test (PPD)

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c. a chest X-ray positive for lung lesion

d. a sputum culture positive for Mycobacterium Tuberculosis

16. A nurse is assessing a client who had a Miller-Abbott tube in place for 24 hours, which
assessed finding indicates that the tube is located in the intestines?

a. bowel sounds are absent

b. the client is nauseous

c. aspirate from the tube has a pH of 7

d. abdominal X-ray reveals that the tube is above the pylorus

17. A physician tells the nurse to obtain a 24-hour urine collection to a client with renal
problem. The nurse avoids which of the following to ensure proper collection of the 24- hour
specimen.

a. discard the first voiding and save all subsequent voiding during the 24 hour time
period

b. have the client void at the end time and place this specimen in the container

c. place the container on ice, or inside a refrigerator

d. have the client void at the start time, and place this specimen in the container

18. A client is admitted to the hospital with a diagnosis of left pneumothorax by chest X-
ray. The client is complaining of difficulty in breathing. Which of the following observed by
the nurse indicates that the pneumothorax is rapidly worsening?

a. pain with respiration

b. Hypertension

c. Tracheal deviation to the right

d. Tracheal deviation to the left

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19. A nurse is caring for a client who is suspected of having a pleural effusion. The nurse
assesses the client, knowing that a typical manifestation of this respiratory problem is:

a. Dyspnea on exertion and moist, productive cough

b. Dyspnea at rest and moist, productive cough

c. Dyspnea on exertion and dry, nonproductive cough

d. Dyspnea at rest and dry, nonproductive cough

20. A physician ordered to administer Apmhotericin B (Fungizone) intravenously to the

client diagnosed with histoplasmosis. The nurse plans to do which of the following during
administration of the medication?

a. assess the intravenous infusion site

b. monitor for hypothermia

c. monitor for an excessive urine output

d. administer a concurrent fluid challenge

21. A client has not voided for 6 hours and has a distended bladder and the nurse
inserted an indwelling Foley catheter. After the tubing is secured and the collection bag is
hung on the bed frame, the nurse notices that 800 ml of urine has drained into the collection
bag. What would be the appropriate nursing action for the safety of the client?

a. clamp the tubing for 30minutes and then release

b. raise the collection bag high enough to slow the rate of drainage

c. provide suprapubic pressure to maintain a steady flow of urine

d. check the specific gravity of the urine

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22. A nurse is caring for a client with a chest tube attached to a Pleurevac drainage
system. Which of the following actions would the nurse must avoid preventing a tension
pneumothorax?

a. clamping the chest tube

b. taping the connection between the chest tube and the drainage system

c. adding water to the suction chamber as it evaporates

d. maintaining the collection chamber below the client’s waist

23. A client with a chest tube attached to a Pleurevac drainage system wants to get out of
bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the
bed rail and disconnects and the Pleur-Evac drainage system falls over and cracks. The nurse
takes which immediate action?

a. clamps the chest tube

b. applies a petroleum gauze over the end of the chest tube

c. immerses the chest tube in a bottle of sterile normal saline

d. calls the physician

24. A nurse is making a plan of care for a female client receiving enteral feedings. The
nurse emphasizes which nursing diagnosis as the highest priority for this client?

a. Risk for Aspiration

b. Risk for Deficient Fluid Volume

c. Imbalanced Nutrition, Less than Body Requirement

d. Diarrhea

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25. A client is scheduled for indirect visualization of the larynx to assess the function of
the vocal cords. As the physician is performing the procedure, the nurse instructed the client
to do which of the following?

a. roll the tongue to the back of the mouth

b. Hold the breath

c. Breathe normally

d. Try to swallow

26. A registered nurse instructed a nursing student to check the breath sound of the
client. As she is observing the nursing student in auscultation, the nurse intervene when the
student perform which of the inappropriate action?

a. places the stethoscope directly to the client’s skin

b. uses the bell of the stethoscope

c. asks the client breathe slowly

d. asks the client to sit up straight

27. A physician tells a nurse to instill otic solution to a adult client left ear. While
performing the procedure, the nurse avoids doing which of the following?

a. placing the tip of the dropper on the edge of the ear canal

b. warming the solution to room temperature

c. placing the client on the side-lying position with the ear facing up

d. pulling the auricle backward and upward

28. A female client has undergone left pneumonectomy. A nurse is formulating a plan of
care to this client. The nurse plans to do which of the following immediate action after the
clients was transferred from the post anesthesia care unit?

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a. position the client supine

b. assist the client to sit in the bedside chair

c. place the client’s intravenous fluid

d. position the client on the left side

29. A client becomes disoriented during the night and at risk for falls. The physician
ordered for vest restraint from 10:00 PM to 7:00 AM. At 11:00 AM the charge nurse makes
rounds on all of the clients with the vest restraints. Which observation by the charge nurse
would indicate that the nurse who cared for this client performed an unsafe action of the use
of the restraint.

a. the restraint was applied tightly

b. a hitch knot was used to secure the restraint

c. the client’s record indicates that the restraint must be released every two hour

d. The call light was placed within reach of the client

30. A physician scheduled the client for pulmonary angiography. The client is fearful
about the procedure and asks the nurse if it is painful and if there is radiation exposure. The
nurse provides reassurance to the client based on the understanding that:

a. There is absolutely no pain, although a moderate amount of radiation must be used

to get accurate result.

b. There is very mild pain throughout the procedure and the exposure to radiation is
negligible

c. The procedure is somewhat painful, but there is minimal exposure to radiation

d. Discomfort my occur with needle insertion and there is minimal exposure to

radiation

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31. A nurse is assigned to care for an anxious client who has an open pneumothorax and
sucking chest wound. An occlusive dressing has been applied to the site. Which of the
following action of the nurse would best relieve the client’s anxiety?

a. Stay with the client as necessary

b. Interpreting the arterial blood gas report

c. Encouraging the client to cough and deep breath

d. Distracting the client with television

32. A female client is to have arterial blood gases drawn. While the nurse is performing
the Allen test, the client asks the nurse about the significance of the test and what procedure
she is doing because no one else has done the same procedure before. The nurse makes
which therapeutic response to the client.

a. “ I assure you that I am doing the correct procedure, I cannot account for what others
do”

b. “This is a routine precautionary step that simply makes certain circulation is intact
before obtaining a blood sample”

c. Oh? “You have questions about this? You should insist that they all do this procedure
before drawing up your blood”

d. This step is crucial to safe blood withdrawal, I would not let anyone take my blood
until they do this”

33. A physician scheduled a male client for an arteriogram using a radiopaque dye. The
nurse assesses which most critical item before the procedure.

a. Allergy to iodine

b. Vital signs

c. Height and weight

d. Intake and output

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34.A nurse has given medication instruction to client who is receiving furosemide (lasix).
The nurse determines that the client needs further instructions if the client states that:

a. ”I need to talk to my physician about the use of alcohol”

b. “I need to avoid the use of salt substitutes because they contain potassium”

c. “I need to be careful not to get overheated in warm weather”

d. “I need to change positions slowly”

35.A nurse is assisting in planning care to a newly admitted client. On entering the room of
the client, the nurse notes that the client’s legs are elevated, the trunk is position flat and the
head and shoulder are slightly elevated. The position of the client is appropriate for
prevention of:

a. Increased Intracranial Pressure

b. Shock

c. A head injury

d. Respiratory insufficiency

36. A nurse is caring for a 12-year old client with chest pain. As she is making her rounds,
she enters the room of her client and finds that the toy is on fire. The nurse immediately
assists the client to get out of the room. What would be the next nursing action in this event?

a. activate the fire alarm

b. call for help

c. extinguish the fire

d. Confine the fire by closing the door of the room

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37.A nurse has just finished suctioning the tracheostomy of a female client. The nurse plans
to monitor the effectiveness of the procedure of which of the following item?

a. respiratory rate

b. oxygen saturation level

c. capillary refill

d. breath sound

38. A nurse is monitoring the status of a client with chest tube. The chest tube is attached
to a Pleur-Evac drainage system. The nurse notes that the fluid in the water seal chamber is
less than 2cm mark. The nurse determines that:

a. water should be added to the chamber

b. there is leak in the system

c. suction should be added to the system

d. this is caused by client pneumothorax

39. A client is admitted to a surgical unit postoperatively with a wound drain in place. A
nurse assesses the client’s surgical incision for sign of infection. Which finding by the nurse
would be interpreted as s normal finding at the surgical site?

a. red, hard skin

b. purulent drainage

c. serous drainage

d. warm, tender skin

40. A nurse in a surgical unit receives a postoperative client form the post anesthesia
care unit. After the initial assessment of the client, the nurse plans to monitor and continue
with post operative assessment activities. Which of the following would be appropriate?

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a. every 15minutes for the first hour, every 30minutes for the second hour, every hour
for 4 hours and then every four hour as needed.

b. every 5minutes for the first half hour, every 15 minutes for two hours, every
30minutes for four hours and then every hour as needed

c. every 30minutes for the first hour, every hour for two hours, then every four hours as
needed

d. every hour for two hours, then every four hours as needed

41. A client with cast on the forearm is complaining of skin irritation from the edges of a
cast. The nurse observes that the skin edges are pink and irritated. The nurse plans to do
which of the following as a corrective action?

a. shake a small amount of powder under the cast rim

b. petal the edges of the cast with tape

c. use hair dryer set on a cool high setting to soothe the irritation

d. Massage the skin at the rim of the cast

42. A family member wishes to donate a blood for the upcoming surgery of the client and
asks the nurse, “How will I know if our blood type will match?” In formulating an
appropriate response, the nurse incorporates that which test will be used to test
compatibility?

a. direct coombs’

b. indirect coombs’

c. monocyte count

d. eosinophil count

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43. A nurse has conducted preoperative teaching for a client scheduled for endoscopic
retrograde cholangiospancreatography (ERCP) procedure. The nurse determines that the
client needs additional teaching if he states that:

a. An anesthetic through spray will be used

b. Medication will be given orally for sedation

c. It is important to lie still during the procedure

d. A signed informed consent is necessary

44. After surgery, the client asks a nurse what is the significance of deep breathing and
coughing. In formulating a response the nurse incorporates the understanding that retained
pulmonary secretion in a post operative client can lead to:

a. Pneumonia

b. pulmonary edema

c. carbon dioxide retention

d. fluid imbalance

45. A nurse is performing tracheostomy care to the client and replaced the tracheostomy
tube holder. The nurse ensures that the tube holder is not too tight by checking if:

a. the client nods that he or she feels comfortable

b. the tracheostomy does not move more than ½ inch when the client is coughing

c. two fingers can be slid comfortably under the holder

d. four fingers can be slid comfortably under the holder

46. A nurse is conducting a preoperative teaching with a client for radical neck
dissection. Initially, the nurse would focus on which piece of information?

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a. information given to the client by the surgeon

b. client’s coping behavior

c. post operative communication techniques

d. client’s support system

47. A female client arrives at the emergency room and scheduled for emergency surgery
because of perforated gastric ulcer. A narcotic analgesic was administered and the client was
sedated and cannot sign the operative consent form. What appropriate nursing action
should be taken in the care of this client?

a. obtain the consent form from family member and have the consent witnessed by two
persons

b. have the hospital chaplain signed the consent form immediately

c. obtain court order for surgery

d. Send the client to surgery without the consent form being signed.

48. A nurse is developing a plan of care to a postoperative client. The nurse assesses the
client for the presence of Homan’s sign and determines that this sign is positive or which of
the following is observed?

a. absent bowel sound

b. incisional pain

c. pain with dorsiflexion of the foot

d. crackles on auscultation of the lungs

49. A nurse is formulating a plan of care for a client scheduled for surgery. On the day of
the operation, the nurse would do which of the following activities in the nursing care plan
for client?

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a. have the client void immediately before surgery

b. avoid oral hygiene and rinsing with mouthwash

c. report immediately any slight increase in blood pressure or pulse

d. verify that the client has not eaten for the last 24 hour

50. A physician ordered to transfuse a unit of packed RBC for an assigned client. In
planning coverage for the client, the nurse just looked for another available nurse to check
the blood to be transfused. Once the blood was double checked, how long will the assigned
nurse stay with the client?

a. 15 minutes

b. 5 minutes

c. 30 minutes

d. 45 minutes

51. A client arrives in the emergency room and is assessed by the nurse. The client
complains of a headache from drinking alcohol and asking for medication. The nurse
explains to the client that assessment must be performed first before the administration of
any medication. The client becomes verbally abusive and the nurse threatens to place the
client in the restraints. Which of the following that the client can legally charge the nurse?

a. Assault

b. Negligence

c. invasion of privacy

d. battery

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52. The nurse is trying to contact the physician who gave an order for a new medication
for the client. The prescribe medication has a high dosage and the nurse is reluctant to
administer. Efforts have been made to look for the physician but the nurse failed to clarify
the order. Which of the following actions should the nurse take?

a. hold the medication until the physician can be contacted

b. administer the dose prescribed

c. administer the recommended dose until the physician can be located

d. contact the nursing supervisor

53. The ICU is understaffed and needs additional nurses to care for the client. The nurse
manager assigned the nurse to report to the ICU for the day. The nurse had no experience in
the ICU. Which of the following is most appropriate nursing action?

a. refuse to work (float) to the ICU

b. call the hospital lawyer

c. call the nursing supervisor

d. report to the ICU and identify tasks that can be performed safely

54. An incorrect dose of a medication was administered by the assigned nurse to a client.
The nurse notifies the nursing supervisor about the error and calls the physician to report
the occurrence. The nurse who administered the medication inaccurately understands that
the:

a. error will result in suspension

b. incident report is a method of promoting quality care and risk management

c. incident will be reported to the BON

d. incident will be documented in the personnel file

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55. A nurse enters the medication room and finds another nurse inside that is about to
insert a needle attached to the syringe containing a clear fluid into the antecubital area. The
nurse appropriate initial action is:

a. call the police

b. call the secure

c. lock the nurse inside the medication room until help is obtained

d. all the nursing supervisor

56. A living will of the client was prepared and the lawyer will be bringing the will to the
hospital as soon as possible for witness signature. The client asks help from the nurse to
obtain a witness to his will. The most appropriate response to the clients is which of the
following?

a. “I will sign as a witness to your signature”

b. “You will need to find a witness on your own”

c. “I will call the nursing supervisor to seek assistance regarding your request”

d. “Whoever is available at the time will sign as a witness for you”

57. A nurse has made an inaccurate documentation on her assessment on a client and
obtains the client’s record to correct the error. Which action should the nurse take to correct
the error?

a. using whiteout to delete the error and writing the correct data

b. trying to erase the error for space to write in the correct data

c. documenting a late entry into the client’s record

d. drawing one line through the error, initialing and dating the line and then
documenting the correct data

58. The laboratory personnel instructed the nurse that the result of the laboratory test of
the client will be forwarded through facsimile machine. After 20minutes the facsimile
machine activates and the nurse is expecting to receive the laboratory result but instead
receives a sexually oriented photograph. The most appropriate nursing action is to:

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a. call the laboratory department and ask for the individual’s name that sent the
photograph

b. cut up the photograph and throw it away

c. call the nurse manager and show the photograph and throw it away

d. call the nursing supervisor and report the incident

59. A nurse is discussing to the nursing students about the right of the clients. The nurse
asks the student to identify a scenario that would represent invasion of privacy of the client.
Which of the following, if identified by the nursing student, indicates an understanding of a
violation of this client right?

a. threatening to give a client a medication

b. performing a procedure without consent

c. telling the client that he/she cannot leave the hospital

d. observing care provided to the client without the client’s permission

60. The nursing instructor provides a lecture to the nursing students regarding some
rights of the clients. The instructor asks the student to identify a situation that represents an
example of battery. Which of the following items indicates an understanding of a violation of
this right?

a. performing a procedure without consent of the client

b. sharing the client’s record to other personnel not involve in providing care

c. threatening the client that he cannot leave the hospital

d. threatening to give a client a medication

61. The nursing staff taking their morning breaks. One of the nursing assistants tells the
group that the ward supervisor has acquired immunodeficiency syndrome. The nursing

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assistant proceeds to tell the nursing staff that the supervisor probably got the disease from
her drug addict husband. Which legal tort has the nursing assistant violated?

a. Libel

b. Slander

c. Assault

d. Negligence

62. A nurse is making rounds and hears one of the clients is calling for help. A nurse
immediately checks the client and finds it lying on the floor. The nurse assisted the client
back to bed and performs a thorough assessment. The incident was documented and the
physician was notified. Which of the following would the nurse documents on the incident
report?

a. the client climbed over the side rails

b. the client fell out of bed

c. the client became restless and tried to get out of bed

d. the client was found lying on the floor

63. A client is rushed to the emergency room. The client sustained a severe head injury,
multiple fractures, and unconscious. An emergency craniotomy is required. Regarding
informed consent for the surgical procedure, which of the following is the best action?

a. call the police to identify the client and locate the family

b. ask the medical emergency team to sign the informed consent

c. transport the client to the operating room for surgery without consent

d. obtain a court order for surgical procedure

64. A nurse is administering a medication to a client but refuses to take the prescribed
medication. The nurse threatens the client telling if the medication is not taken orally, then
it will be given by injection. This action by the nurse constitutes which legal tort?

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a. invasion of privacy

b. negligence

c. assault

d. battery

65. The nurse is reviewing the prescribed medication of a newly admitted client. The
nurse reviewed the order and notes that the physician has ordered the dose that is twice the
amount the client is taking before admission. The nurse verifies the medication dosage
before the administration. What is the next most appropriate nursing action?

a. administer the drug even the dosage is twice the amount because that is the order of
the physician

b. Verify the prescribed medication by calling the nurse supervisor

c. Contact the physician and verifies the order

d. Carry out the order because there is no question about it

66. A client is scheduled for a cardiac catheterization and has numerous questions
regarding the procedure and has requested to speak to the physician. The nurse calls the
physician and informs that the client wants to talk to him. When the physician arrives at the
unit to visit the client he is very upset with the nurse. The nurse is outside the client’s room
and hears the physician tells the client in a derogatory manner that the nurse “doesn’t know
anything”. Which legal tort has the physician violated?

a. Slander

b. Libel

c. Assault

d. Negligence

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67. An individual wishes to donate his organ for transplantation. The person asks the
nursehow to become an organ donor. The nurse includes which statement in the response to
the client?

a. the donor must be 25 years of age or older

b. the family is responsible for making organ donor decision at the time of death

c. the donation is done by written consent

d. the witness and a family member must be present to sign a form if an individual
wants to donate his or her own organs for transplant.

68. A client has returned to the nursing unit after surgery. A nurse is assigned to monitor
the client’s condition. Over the past four hour, the client’s vital signs are deteriorating and
the nurse does not recognize the significance of these changes in vital signs and take no
action. The client later requires emergency surgery. The nurse could be prosecuted for
inaction according to the definition of which of these terms?

a. Tort

b. Misdemeanor

c. Common Law

d. Statutory Law

69. A client, which as a famous police officer, is admitted to the hospital with a diagnosis
of Parkinson’s disease. The nurse gives medical information regarding the client’s condition
to a person who is assumed to be a family member. Later, the nurse found out that this
person is not a family member of the client and the nurse realizes that she has violated
which legal concept of the nurse-client relationship?

a. performing focused physical assessment

b. client’s right to privacy

c. nurse’s lack of experience

d. teaching and learning principles

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70. A nurse was hired to be a home care nurse to assist the family in caring for a newborn
with congenital tracheoesopahgeal fistula who is receiving enteral feedings. The nurse
receives a telephone call and a woman introduced herself to the nurse as a family friend and
wishes to know the condition of the client and inquire if there is anything she can do to assist
the parents. The best nursing action is to:

a. inform the friend that the family has no need for assistance at this time because the
nurse is making daily visits

b. inform the friend to directly contact the family and offer her assistance to them

c. report the friend’s telephone call to the nurse manager for referral to the client’s
social worker

d. request that the friend come to the client’s home, where she can be taught to
administer the feedings

71. A nurse is assigned to care for a male client recovering home from a disabling lung
infection. In her assessment of the health history of the client, the nurse found out that the
infection is probably the result of HIV. The nurse is a religious person and informs the client
that she is morally opposed to homosexuality and cannot care for him. The nurse then leaves
the client’s home. Which of the following is true regarding the nurse’s actions?

a. the nurse has a duty to provide competent care to assigned clients in a

nondiscriminatory manner

b. the nurse has the right to refuse to care for any client without justifying that refusal

c. the nurse has the duty to protect self from client care situations that are morally
repellent

d. the nurse has a legal right to inform the client any barriers in providing care

72. A client diagnosed with cancer wishes to speak to his lawyer. The nurse contacted the
lawyer to visit the client in the nursing unit. The client requested the lawyer to prepare a
living will. The client requested the nurse to be the witness for the will. The nurse takes
which appropriate action?

a. refuse to help the client because it is against the agency policy

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b. agrees to act as a witness, anyway it is the client’s last request

c. informs the client that a nurse caring for a client cannot serve as a witness to a living
will

d. calls the physician to act as one of the witness

73. The nurse is caring to a client diagnosed with leukemia. The client asks the nurse
about how to prepare a living will. The nurse informs the client that the first step to do in
preparing this document is to:

a. talk to the hospital chaplain

b. consult with the cancer society

c. contact a lawyer

d. discuss the request with the physician

74. A nurse is assigned to care for a newly admitted client with a diagnosis of a bowel
tumor. During the assessment period, the client tells the nurse that he prepared a living will
four years ago. The client asks the nurse if this will is still effective. The nurse makes which
appropriate response to the client?

a. “yes it is”

b. “you will have to ask your lawyer”

c. “is should be reviewed yearly with your physician”

d. “I have no idea”

75. A nurse is assigned to a client scheduled for a colonoscopy and the physician has
provided detailed information to the client about the procedure. After confirming if the
client clearly understands the procedure, the nurse prepares the informed consent for the
client to sign it. Then the client informs the nurse that he does not know how to write. What
is the nurse appropriate action?

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a. contact a family member to represent for the client and sign the inform consent form

b. contact the physician and inform that the client cannot write

c. obtain a second nurse to also act as a witness and ask the client to sign the form with
an X

d. send the client for the procedure without a signed informed consent

76. A Clinical Instructor is lecturing professional liability insurance with the graduating
nursing students. The Instructor should advise the nursing students who will be graduating
in the next month:

a. that most lawsuits are filed against physician

b. that malpractice insurance is not required and expensive

c. to obtain their own malpractice insurance

d. to discuss liability insurance with the employment agency

77. A client who had a colon resection is given a regular diet. The client refuses to eat
solid food and asked that the physician be called. The nurse insisted that the solid food is an
advised diet. The client was convinced and ate the food that was offered. Subsequently, the
client had emergency surgery as a result of complications. The determination of negligence
in this situation is based on:

a. the nurse’s persistence

b. a duty existed and it was breached

c. not calling the physician

d. the dietary department sending the wrong food

78. The Registered Nurse working in the emergency room observes that his co-worker is
not performing well in providing care to the client. He suspects that his /her co-worker is
substance impaired and notes signs of alcohol intoxication. The Nurse Practice Act requires
that the Registered Nurse do which of the following

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a. ask the colleague to go to the nurse’s lounge to sleep for a while

b. talk with the colleague

c. report the information to a nursing supervisor

d. call the impaired nurse organization

79. A nurse lawyer is conducting an educational session to the nursing staff regarding
client rights. The nursing staff requested the lawyer to give an example that may give them a
clear idea relating to invasion of client privacy. Which of the following indicates a violation
of this right?

a. performing a surgical procedure without consent

b. telling the client that he/she cannot leave the hospital

c. taking photographs of the client without consent

d. threatening to place a client in restraints

80. A home care nurse arrives at the client’s home for the scheduled home visit. The
client tells the home care nurse of his decision to refuse external cardiac massage. Which of
the following is the most appropriate initial nursing action?

a. discuss the client’s request with the family

b. notify the physician of the client’s request

c. conduct a client conference with the home care staff to share the client’s request

d. document the client’s request in the home care nursing care plan

81. A newly hired staff nurse is attending an orientation regarding the nursing model of
practice implemented in the agency’s facility. The nurse was informed that the model of
practice used is a team nursing approach. The nurse understands that the nursing care
delivery will be patterned on which characteristic of this type of nursing model of practice?

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a. single registered nurse is responsible for providing nursing care to a group of client

b. a task approach method is used to provide care to clients

c. managed care concepts and tools are used to provide care to client

d. nursing personnel are led by an RN leader in providing to a group of client

82. The nurse was informed that the nurse manager has implemented change in the
method of the nursing delivery system. The delivery system was changed from functional to
team nursing. A nursing assistant was reluctant to the change and is not taking an active part
in facilitating the process of change. Which of the following would be best approach in
dealing with the nursing assistant?

a. provide a positive reward system for the nursing assistant

b. ignore the resistance

c. exert coercion with the nursing assistant

d. confront the nursing assistant to encourage verbalization of feelings regarding the

change

83. The nurse is formulating the client assignment for the day. Which of the following is
the most appropriate assignment for the nursing assistant?

a. a client with difficulty swallowing food and fluids

b. a client who requires a colostomy irrigation

c. a client receiving continuous tube feeding

d. a client requires urine specimen collection

84. The nurse manager implemented team nursing approach in the unit and planning
assignments for the clients. The RN needs to assign four clients and has a licensed practical
nurse and three nursing assistant on a team. Which of the following clients would the nurse
most appropriately assign to the licensed practical nurse?

a. a client who requires a bed bath

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b. an older client requiring frequent ambulation

c. a client who requires a Fleet enema

d. A client with an abdominal wound requiring wound irrigation and dressing change
every 3 hours

85. On the day shift, the registered nurse has just received an assignment. While making
initial rounds and checking all the assigned clients, which clients will the registered nurse
give first priority of care?

a. a post operative client who has just received pain medication

b. a client who is ambulatory

c. a client scheduled for physical therapy at 1 PM

d. a client with a fever who is diaphoretic and restless

86. The nurse was given an assignment to care for four clients. At the start of the rounds,
the nurse develops a plan. Which client would the nurse assess first?

a. a client requiring every day dressing change

b. a client scheduled for a chest X-ray

c. a client receiving oxygen via nasal cannula who had difficulty breathing during the
previous shift

d. a postoperative client preparing for discharge

87. The nurse was assigned to perform bed bath to the client. The nurse assistant enters
the client room and tells the nurse that another assigned client is in pain and needs pain
medication. The most appropriate nursing action is which of the following?

a. cover the client, raise the side rails, tell the client that you will return shortly, and
administer the pain medication to other client

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b. finish the bed bath and then administer the medication to other client

c. Ask the nursing assistant to tell the client in pain that medication will be
administered as soon as the bed bath is complete.

d. Ask the nursing assistant to find out when the last medication was given to the client.

88. The home health care is formulating a plan of visit to the clients for the day. The
nurse is scheduled to visit a client requiring twice daily abdominal dressing changes.
Another client to be seen is a client whose spouse is performing daily dressing changes. The
nurse is also assigned to admit a client who was discharged yesterday from the hospital
following a diagnosis of pneumonia. The last client to be seen will be visited by a home
health aide and the nurse needs to orient the aide and provide supervision of client care. The
client decided to begin the visit in the morning and clients live within a 5-mile radius. How
would the nurse start the assignment for the day?

a. the client requiring admission, the client regarding supervision of the dressing
change, client requiring twice daily dressing changes, client being visited by the home health
aide, client requiring a second twice daily dressing change

b. client requiring twice daily dressing changes, client being visited by the home health
aide, the client regarding supervision of the dressing change, the client requiring admission,
the client requiring the second twice daily dressing change

c. client being visited by the home health aide, the client requiring admission, the client
regarding supervision of the dressing change client requiring twice daily dressing changes,
client requiring second twice daily dressing changes

d. the client being visited by the home health aide, client requiring twice daily dressing
changes, the client requiring admission, the client regarding supervision of the dressing
change, the client requiring the second twice daily dressing change

89. In a night shift, a nurse was in-charged in the emergency department and is assigned
to triage clients arriving to the emergency room for treatment. The nurse would assign
highest priority to which of the following clients?

a. client complaining of muscle aches, headache, and malaise

b. client with chest pain who states that he just ate pizza that was made with a very
spicy sauce

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c. client who twisted her ankle when she fell while rollerblading

d. client with minor laceration on the index finger sustained while cutting an eggplant

90. The nurse on the day shift is scheduled to care for three clients. One client is
scheduled for a cardiac catheterization at 10AM; the other has a tracheostomy and is on a
mechanical ventilator. And the other client was newly diagnosed with diabetes mellitus and
is scheduled for discharged to home. How would the nurse plan the order of care of the
clients for the day?

a. a client with diabetes mellitus, client scheduled for a cardiac catheterization, client
with tracheostomy

b. a client scheduled for a cardiac catheterization, client with diabetes mellitus and for
discharged to home, client with tracheostomy

c. a client with tracheostomy and is on mechanical ventilator, client scheduled for a

cardiac catheterization followed by the client with diabetes mellitus scheduled for
discharged.

d. A client with tracheostomy and scheduled for cardiac catheterization would at the
same time be given the highest priority in the plan of care, client for discharge does not need
much attention

91. A registered nurse is delegating a task to the nursing staff. Which among the tasks
listed is a least appropriate to the nursing assistant?

a. accompanying a man being discharged to his transportation to home

b. assisting a post cardiac catheterization client who needs to lie flat to eat lunch

c. collecting a urine specimen from a client

d. obtaining frequent oral temperature on a client

92. A nurse has a licensed practical nurse on the nursing team. In planning the client
assignments, which client would the nurse most appropriately assign to the LPN?

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a. a client who was treated for dehydration and is weak and needs assistance with
bathing

b. a client who is scheduled for an electrocardiogram and a chest X-ray

c. a client with stable congestive heart failure who has early stage Alzheimer’s disease

d. a client with emphysema who is receiving oxygen at 2L by nasal cannula and becomes
dyspneic on exertion

93. A nurse manager conducting a forum with the nursing staff regarding concerns and
proposals for actions related to the nursing unit. The nurse manager discusses her/his
opinion, own analysis of the problem and proposals for action to team members, and invites
each member to comment and provide input. Which style of leadership is the nurse manager
specifically employing?

a. laissez fair

b. authoritarian

c. situational

d. participative

94. A registered nurse assigned the licensed practical nurse to change the colostomy bag
on a client. The LPN informed the registered nurse that he/she has no experience in
performing the procedure on a client and was afraid he/she might not do it correctly. The
appropriate action of the registered nurse is to:

a. Request that the LPN review the materials from the inservice before performing the
procedure

b. Request that the LPN observes another LPN perform the procedure

c. Perform the procedure with the LPN

d. Request that the LPN review the procedure in the hospital manual and bring the
written procedure into the client’s room for guidance during the procedure

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95. A newly nursing graduate is attending an orientation regarding the nursing model of
practice implemented in the hospital. The nurse is told that the nursing model is a primary
nursing approach. The nurse understands that which of the following is a characteristic of
this type of nursing model of practice?

a. critical paths are used in providing client care

b. the nurse manager assigns tasks to the staff members

c. a single registered nurse is responsible for planning and providing individualized

nursing care

d. Nursing staff are led by an RN leader in providing care to a group of clients

96. A nurse manager is providing a lecture for the staff nurses about case management. The nurse
manager determines that a review of the material needs to be done if a staff nurse stated that case
management:

a. is designed to promote appropriate use of hospital personnel and material resources

b. represents a primary health prevention focus managed by a single case manager

c. manages client care by managing the client care environment

d. maximizes hospital revenues while providing for optimal outcome of client care

97. A registered nurse is in-charge in preparing the assignments of the nursing staff in the nursing
unit for the day. The registered nurse assign a nursing assistant to make beds and bathe one of the
clients on the unit and assigns another nursing assistant to fill the water pitchers and serve juice to all
of the clients. Another registered nurse in the nursing unit is assigned to administer all medication.
Based on the assignments scheduled by the registered nurse, which type of nursing care is being
practiced?

a. primary nursing

b. team nursing

c. functional nursing

d. exemplary model of nursing

98. A hospital administration has implemented a new method in the distribution of

assignments of nurses to nursing units. Nurses will now be required to work in other

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nursing department and will not be specifically assigned to a nursing unit. A group of
registered nurse is resistant to the change and nursing administration anticipates that the
nurses will not facilitate the process of change. Which of the following would be the best
approach on the part of administration in dealing with the resistance?

a. manipulate the nurses to participate in the change

b. ignore the resistance

c. confront the nurses to encourage verbalization of feelings regarding the change

d. exert coercion with the nurses

99. A nurse manager is formulating a plan to implement a new method of documentation

system in the nursing unit. Many problems have encountered as a result of the present
documentation system, and the nurse manager determines that a new system must be used.
The initial step in the process of using a new system for the nurse manager is which of the
following?

a. identify potential solutions and strategies for the new system

b. plan strategies to implement the change

c. set goals and priorities regarding the change process

d. identify the inefficiency that needs improvement or correction

100. A nurse in charge observes that the staff nurse is not providing quality care to the
client, not able to meet Client’s needs in a reasonable time frame, does not solve any
problems in the nursing unit and does not prioritize nursing care. Which of the following is
the responsibility of the charge nurse?

a. report the staff nurse to the supervisor so that something is done to resolve the
problem

b. supervise the staff nurse more closely so tasks are completed

c. provide support and identify the underlying cause of the staff nurse’s problems

d. ask other staff members to help the staff nurse get the work done

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Test I - Foundation of Nursing, Nursing Research, Professional Adjustment, Leadership
and Management

ANSWERS AND RATIONALE

1. ANSWER: C
RATIONALE: The nurse should immediately return the unit of blood to the blood bank. The
presence of gas bubbles in the bag indicates possible bacterial growth and unit is considered
contaminated

2. ANSWER: C
RATIONALE: The first layer of the chest tube dressing is petrolatum gauze which allowed for an
occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the
dressing is secured with a strong adhesive tape or Elastoplast tape.

3. ANSWER: C
RATIONALE: FORMULA

DROP/MIN = TOTAL VOLUME IN CC x DROP FACTOR

NO. OF HOURS X 60 MINS

= 1000ml x 15gtts
8 HRS.(60 MINS)

= 15000
480

= 31.2 or 31gtts/mins

4. ANSWER: B
RATIONALE: Pharyngeal reflex (gag reflex) is tested by touching the back of the throat with an
object, such as a tongue depressor. It is considered normal if there is a positive response to
these reflexes.

5. ANSWER: D
RATIONALE: The normal serum amylase is 25 to 151 IU/L. In client with chronic pancreatitis,
the increase in serum amylase does not exceed 3 times the normal value.

6. ANSWER: C
RATIONALE: The nurse should ask the client to perform Valsalva’s maneuver during tubing
change this maneuver would help the client to avoid air embolism during the procedure

7. ANSWER: C
RATIONALE: If client developed uncontrolled atrial fibrillation with a ventricular rate over 100
beats per minute, the client may experience low cardiac output caused by loss of atrial kick. The
nurse assesses the client for palpitation, chest pain, or discomfort, hypotension, pulse deficit,
fatigue, weakness, dizziness, shortness of breath and distended neck veins.

8. ANSWER: A
RATIONALE: The solution containing the highest amount of glucose should be hung until the
new TPN becomes available. The 10% water solution is the best because it minimizes the risk of
hypoglycemia

9. ANSWER: A
RATIONALE: A dry sterile dressing such as 2x2 gauze is used to apply pressure to the
discontinued IV site. This material is absorbent, sterile and non-irritating.

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10. ANSWER: A
RATIONALE: Desire
Available x ml = 30mEq/ 40mEq x 20ml = 15ml

11. ANSWER: C
RATIONALE: After liver biopsy, the client is assisted to assume right side-lying position with a
small pillow or folded towel because it compresses the liver against the chest wall at the biopsy
site.

12. ANSWER: C
RATIONALE: The lung is collapsed; therefore, there are no breath sounds during auscultation

13. ANSWER: A
RATIONALE: If the balloon is positioned in the urethra, inflating the balloon could produce
trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted
a little further in order to provide sufficient space to inflate the balloon.

14. ANSWER: C
RATIONALE: All IV solutions should be free of particles or precipitates. The nurse must check
the solution before the procedure.

15. ANSWER: D
RATIONALE: The most accurate means of confirming the diagnosis of Tuberculosis is by sputum
culture

16. ANSWER:C
RATIONALE: The Miller-Abbott tube is a nasogasenteric tube that is used to decompresses the
intestine and to correct a bowel obstruction

17. ANSWER: D
RATIONALE: The nurse asks the client to void at the beginning of the collection period and
discard the unit sample

18. ANSWER: C
RATIONALE: A pneumothorax is characterized by distended neck veins, displaced point of
maximal impulse (PMI), and subcutaneous emphysema, tracheal deviation to the unaffected side,
decreased fremitus, and worsening cyanosis.

19. ANSWER: C
RATIONALE: Typical assessment findings in the client with a pleural effusion include Dyspnea,
which usually occurs with exertion, and a dry nonproductive cough. The cough is caused by
bronchial irritation and possible mediastinal shift.

20. ANSWER: A
RATIONALE: Apmhotericin B is a toxic medication, which can produce symptoms during
administration such as chills, fever, headache, vomiting, and impaired renal function. The
medication is very irritating to the IV site, commonly causing thrombophlebitis. The nurse
administering this medication monitors for these complications.

21. ANSWER: A
RATIONALE: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood
vessels and hypovolemic shock. Clamping the tubing for 30minutes allows for equilibration to
prevent complication.

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22. ANSWER: A
RATIONALE: To prevent a tension pneumothorax, the nurse avoids clamping the chest tube,
unless specifically ordered. Clamping the chest tube is contraindicated by agency policy

23. ANSWER: C
RATIONALE: If a chest tube accidentally disconnects from the tubing of the drainage apparatus,
the nurse should first reestablish an underwater seal to prevent tension pneumothorax and
mediastinal shift. This can be accomplished by reconnecting the chest tube, or in this case,
immersing the end of the chest tube in a bottle of sterile normal saline or water. The physician
should be notified after taking the corrective action.

24. ANSWER: A
RATIONALE: Any condition in which gastrointestinal motility is slowed or esophageal reflux is
possible places a client at risk for aspiration.

25. ANSWER: C
RATIONALE: Indirect laryngoscopy is done to assess the function of the vocal cords or to obtain
tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror.
The client is placed in an upright position to facilitate passage of the laryngeal mirror into the
mouth and is instructed to breathe normally. The tongue cannot be moved back because it would
occlude the airway. Swallowing can not be done with the mirror in place. The procedure takes
longer that the time the client would be able to hold the breath, and this action is ineffective.

26. ANSWER:B
RATIONALE: The bell of the stethoscope is not use to auscultate the breath sounds. The client
ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the
stethoscope which is warmed before use, is placed directly on the client’s skin, not over a gown
or clothing.

27. ANSWER: A
RATIONALE: The dropper is not allowed to touch any object or any part of the client’s skin. The
solution is warmed before use. The client is placed on the side with the affected ear upward. The
nurse pulls the auricle backward and upward to adult client and instills the medication by holding
the dropper about 1cm above the ear canal

28. ANSWER: C
RATIONALE: Following pneumonectomy, the fluid status of the client is monitored closely to
prevent fluid overload, because the size of the pulmonary vascular bed has been reduced as a
result of pneumothorax. Complete lateral turning and positioning is avoided. The client should
remain on bed rest and the head of the bed should be elevated to promote lung expansion.

29. ANSWER: A
RATIONALE: Restraint should be applied securely not tightly because it could impair circulation

30. ANSWER: D
RATIONALE: Pulmonary angiography involves minimal exposure to radiation. The procedure is
painless although the client may feel discomfort with insertion of the needle for the catheter that is
used for dye injection.

31. ANSWER: A
RATIONALE: Staying with the client has a two-fold benefit. First, it relieves the anxiety of the
dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after
application of the occlusive dressing.

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32. ANSWER: B
RATIONALE: The Allen test is performed to assess collateral circulation in the hand before
drawing a radial artery blood specimen. The therapeutic response provides information to the
client.

33. ANSWER: A
RATIONALE: The procedure involves the injection of radiopaque dye into the blood vessel. If the
client has allergy to iodine the procedure will not be advised to prevent complications of the
client’s reaction to the dye.

34. ANSWER: B
RATIONALE: Furosemide is a potassium-losing diuretic, so there is no need to avoid high-
potassium product such as a salt substitute. Orthostatic hypotension is a risk. And the client must
caution with changing position and with exposure to warm weather. The client needs to discuss
the use of alcohol with the physician.

35. ANSWER: B
RATIONALE: A client in shock is placed in a modified Trendelenburg position that includes
elevating the legs, leaving the trunk flat and elevated head and shoulders. This position promotes
increase venous return from the lower extremities without compressing the abdominal organ
against the diaphragm.

36. ANSWER: A
RATIONALE: The order of priority in the event of fire is to rescue the clients who are in
immediate danger. The next step is to activate the alarm. The fire then is confided by closing the
door and last the fire is extinguished

37. ANSWER: D
RATIONALE: After suctioning, client either with or without artificial airway, the breath sounds are
auscultated to determine the extent to which the airways have been cleared of respiratory
secretions. The other assessment items are not as precise as breath sounds.

38. ANSWER: A
RATIONALE: The water seal chamber should be filled to the 2cm mark to provide an adequate
water seal between the external environment and the client’s pleural cavity. The water seal
prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse
should solve this problem by adding water until the level is gain at the 2cm mark

39. ANSWER: C
RATIONALE: Serous drainage is an expected finding at a surgical site. The other options
indicate sign of wound infection.

40. ANSWER: A
RATIONALE: When the post operative client arrives from the post anesthesia care unit, the
nurse performs an initial assessment. Common time frames for continuing postoperative
assessment activities are every 15 minutes for the first hour, every 30 minutes for the second
hour, and then every hour for four hours and every four hour as needed.

41. ANSWER: B
RATIONALE: The nurse should petal the edges of the cast with tape to minimize skin irritation. A
hair dryer is used on a cool low setting if a non plaster cast becomes wet. Massaging the skin will
not help. Powder should not be shaken under the cast, because it could clump, becomes moist,
and cause skin breakdown.

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42. ANSWER: B
RATIONALE: The indirect coombs’ test detects circulating antibodies against red blood cells and
is the “screening” component to type and screen the client’s blood. This test is used in addition to
ABO typing, which is normally done to determine blood type.

43. ANSWER: B
RATIONALE: The client needs to lie still for ERCP, which takes about an hour to perform. An
informed consent must be signed. Intravenous sedation (NOT ORALLY) is given to relax the
client. The anesthetic spray is used to help keep the client from gaggling as the endoscope is
passed.

44. ANSWER: A
RATIONALE: The most common post operative respiratory problems are atelectasis, pneumonia
and pulmonary emboli. Pneumonia is inflammation of lung tissue that causes productive cough,
dyspnea and crackles.

45. ANSWER: C
RATIONALE: There should be enough room for two fingers to slide comfortably under the
tracheostomy holder. This ensures that the holder is tight enough to present tracheostomy
dislocation, while preventing excessive constriction around the neck.

46. ANSWER: A
RATIONALE: The first step to client education is establishing what client already knows. This
allow the nurse to not only connect any misinformation but also to determine the starting point for
teaching and to implement the education of the client’s level.

47. ANSWER:A
RATIONALE: Every effort must be done to obtain permission from a responsible family member
to perform surgery if the client is unable to sign the consent form. Telephone consent must be
witnessed by two persons who hear the family oral consent. The two witnessed sign the consent
noting that an oral consent was obtained.

48. ANSWER: C
RATIONALE: To elicit Homan’s sign, the nurse would dorsiflex the client’s foot and assesses the
client for pain in the calf area. If pain is present, a positive Homan’s sign is present.

49. ANSWER: A
RATIONALE: The nurse would assist the client to void immediately before surgery so that the
bladder will be empty. Any trauma or accidental puncture to the bladder is avoided.

50. ANSWER: A
RATIONALE: The nurse must remain with the client for the first 15 minutes of transfusion which
is the most frequent period of danger of transfusion reaction. This enables the nurse to detect
reactions and intervene quickly.

51. ANSWER: A
RATIONALE: An assault occurs when a person puts another person in fear of a harmful of
offensive contact.

52. ANSWER: D
RATIONALE: If the physician writes an order that requires confirmation, the nurse’ responsibility
is to contact the physician for clarification. If there is no resolution regarding the order because
the physician cannot be located and because the order remains as it was written after talking to
the physician, the nurse then should contact the nurse manager or supervisor for further
clarification as to what the next step should be.

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53. ANSWER: D
RATIONALE: Floating is an acceptable legal practice used by hospitals to solve their
understaffing problems. Legally, a nurse cannot refuse to float unless a union contract
guarantees that nurses can work only in a specified area or can prove the lack of knowledge for
the performance of assigned task.

54. ANSWER: B
RATIONALE: Documentation of unusual occurrence, incident, accidents and the nursing actions
taken as a result of the occurrence allows the nurse to review the quality of care and determine
any potential risks present.

55. ANSWER: D
RATIONALE: Nurse Practice acts require reporting impaired nurses. This incident needs to be
reported to the nursing supervisor, who will then report to the board of nursing and authorities.

56. ANSWER: C
RATIONALE: Living will are required to be in writing and signed to the client. The client’s
signature either must be witnessed by specified individuals or notarized. Many states prohibit any
employee even a nurse of a facility where the client is receiving care from being a witness.

57. ANSWER: D
RATIONALE: If the nurse makes an error in documenting in the client’s record, the nurse should
follow agency policies to correct the error in the documentation. This includes drawing one line
and then documenting the correct information.

58. ANSWER: D
RATIONALE: Sexual harassment in the workplace is prohibited by state and federal law.
Sexually suggestive jokes, touching, pressuring a co-worker for a date and open displays of
sexually oriented photograph are examples of conduct that could be considered sexual
harassment. If the nurse believes that he/she is being subject to unwelcome sexual conduct,
these concerns should be reported to the nursing supervisor immediately.

59. ANSWER: D
RATIONALE: Invasion of privacy takes place with unreasonable intrusion into an individual’s
private affairs.

60. ANSWER: A
RATIONALE: Performing a procedure without consent of the client is a form of battery.
Threatening the client to give medication is an example of assault. Threatening the client cannot
leave the hospital constitute false imprisonment and sharing the client’s data is a form of invasion
of privacy.

61. ANSWER: B
RATIONALE: Slander or Defamation takes place when something untrue is said about a person
resulting injury to that person’s good name and reputation.

62. ANSWER: D
RATIONALE: The report should contain a factual description of the incident, any injuries
experienced by those involved and the outcome of the situation

63. ANSWER: C
RATIONALE: Generally, in only two instances is the informed consent of an adult client not
needed. First, is when emergency is present and delaying treatment for the purpose of obtaining
informed consent would result in injury of death to the client. Second, is when the client waives
the right to give informed consent.

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64. ANSWER: C
RATIONALE: An assault occurs when person puts another person in fear of a harmful or
offensive contact. For this intentional tort to be actionable, the client must be aware of the threat.

65. ANSWER: C
RATIONALE: If the nurse determines that a physician’s order is unclear, or if the nurse has a
question about an order, the nurse should contact the physician, before implementing the order.
Under no circumstances should the nurse carry out the order unless the physician has clarified
the order.

66. ANSWER: A
RATIONALE: Slander/Defamation takes place when something untrue is said (slander) or written
(libel) about a person resulting in injury to that person’s good name or reputation

67. ANSWER: C
RATIONALE: The client has the right to donate her or his organs for transplantation. Any person
18years or older may become an organ donor by written consent. In the absence of appropriate
documentation, a family member or legal guardian may authorize donation of the decedent’s
organs

68. ANSWER: A
RATIONALE: Tort is a wrongful act intentionally or unintentionally committed against a person or
his or her property. The nurse’s inaction in the situation described is consistent with the definition
of a tort offense.

69. ANSWER: B
RATIONALE: Discussing a client’s condition without client permission violates a client’s right and
places the nurse on legal jeopardy. This action by the nurse is both an invasion of privacy and
affects the confidentiality issue with the client rights.

70. ANSWER: B
RATIONALE: A nurse must uphold the client’s rights and does not give any information regarding
a client’s care needs to anyone who is not directly involved in the client’s care. To request that the
friend come for teaching is a direct violation of the client’s right to privacy. There is no information
in the question to indicate that the family desires assistance form the friend. To refer the call to
the nurse manager and social worker again assumes that the friend’s assistance and involvement
is desired by the family. Informing the friend that the nurse is visiting daily is providing information
that is considered confidential.

71. ANSWER: A
RATIONALE: The nurse has a duty to provide care to all clients in a nondiscriminatory manner.
Personal autonomy does not apply if it interferes with the rights of the clients. There is no legal
obligation to inform the client of the nurse’s personal objections to the client. Refusal to provide
care may be acceptable if that refusal does not put ht e client’s safety at risk and the refusal is
primarily associated with religious objections, not personal objection to lifestyle or medical
diagnosis. The nurse also has an obligation to observe the principle of nonmaleficence.

72. ANSWER: C
RATIONALE: A living will addresses the withdrawal or withholding of life sustaining intervention
that unnaturally prolong life. It identifies the person who will make care decisions if the client is
unable to take action. It is witnessed and signed by two people who are unrelated to the client.
Nurses or employees of a facility in which the client is receiving care and beneficiaries of the
client should not serve as a witness. There is no reason to call the physician.

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73. ANSWER: D
RATIONALE: The client should discuss the request for a living will with the physician. The client
should also discuss this desire with the family. Wills should be prepared with legal counsel and
should identify the executor of the state, address distribution and use of property, and the specific
plans for burial. Although the other options may be helpful, their contact would not be the initial
step. The lawyer will be contacted following discussion with physician and family.

74. ANSWER: C
RATIONALE: The client should discuss the living will with the physician, and it should be
reviewed annually to ensure that it contains the client’s present wishes and desires. Although a
lawyer needs to be consulted if the living will be need to be changed.

75. ANSWER: C
RATIONALE: Clients who cannot write may sign an informed consent with an X. This is
witnessed by two nurses. Nurses serve as a witness to the client’s signature and not to the fact
that the client is informed. It is the physician’s responsibility to inform the client about a
procedure. The nurse clarifies facts presented by the physician. There is no useful reason to
contact the physician at this time. A client is not send to a procedure without a signed informed
consent

76. ANSWER: C
RATIONALE: Nurses need their own liability insurance for protection against malpractice
lawsuits. Nurses erroneously assume that they are protected by an agency’s professional liability
policies.

77. ANSWER: B
RATIONALE: For negligence to be proven, there must be a duty, and then a breach of duty; the
breach of duty must cause the injury and damages or injury must be experienced.

78. ASNWER: C
RATIONALE: The Nurse Practice Acts requires reporting the suspicion of the impaired nurses.
The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for
treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will
then report to the Board of Nursing. Confronting the colleague may cause conflict. Asking the
colleague to go to the nurses’ lounge to sleep for a while does not safeguard clients.

79. ANSWER: C
RATIONALE: Invasion of privacy takes place when an individual’s private affairs are
unreasonably intruded into.

80. ANSWER: B
RATIONALE: External Cardiac Massage is a life-saving treatment that a client can refuse. The
most appropriate initial nursing action is to notify the physician, because written do not
Resuscitate (DNR) order from the physician is needed. The DNR order must be reviewed or
renewed on a regular basis per agency policy.

81. ANSWER: D
RATIONALE: In team nursing, nursing personnel are led by a registered nurse leader in
providing care to a group of clients.

82. ANSWER: D
RATIONALE: Confrontation is an important strategy to meet resistance head-on. Faceto- face
meetings to confront the issue at hand will allow verbalization of feelings, identifications of
problems and issues.

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83. ANSWER: D
RATIONALE: The nurse must determine the most appropriate assignment based n the skills of
the staff member and the needs of the client. In this case, the most appropriate assignment for a
nursing assistant would be to care for the client who requires urine specimen collection. The
nursing assistant is skilled in this procedure.

84. ANSWER: D
RATIONALE: When delegating nursing assignment, the nurse needs to consider the skills and
educational level of the nursing staff. The bed bath, fleet enema and assisting the client in
ambulation can be done by the nursing assistant. Licensed Practical Nurse is skilled in wound
irrigation and care.

85. ANSWER: D
RATIONALE: A nurse would plan to care first a client who had a fever and restless because the
client’s needs are the priority. Waiting for pain medication to take effect before providing care to
the post operative client is best.

86. ANSWER: C
RATIONALE: An airway is always a high priority, and the nurse would attend to the client who
has been experiencing an airway problem first

87. ANSWER: A
RATIONALE: The nurse is responsible for the care provided to the assigned clients. The most
appropriate action is to provide safety to the client who is receiving the bed bath and prepare to
administer the pain medication.

88. ANSWER : B
RATIONALE: The nurse would plan to see the client requiring twice daily dressing changes first
because the dressing changes should be spaced as far apart as possible. The nurse next plan
would be the client being visited by the home health aide and provide instructions and direction to
the aide regarding health care to the client. The nurse then would to see the client regarding
supervision of the dressing change and would perform the admission last because that may take
more time than the other clients. The nurse then would return to the client regarding second twice
daily dressing

89. ANSWER: B
RATIONALE: In an emergency department, triage is classifying clients according to priorities of
care. The kind of illness, severity of the problem, and the resources available govern the process.
Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation,
acute neurological deficits, and those who sustained chemical splashes to the eyes are classified
as emergent and are the number one priority.

90. ANSWER: C
RATIONALE: Airway is always a high priority and the nurse would assess the client who has a
tracheostomy and is on a mechanical ventilator first. The nurse next step of care would assess
the client scheduled for cardiac catheterization, followed by the client scheduled for discharge.

91. ANSWER: B
RATIONALE: Work that is delegated to others must be done consistent with the individual’s level
of expertise and licensure. Based on the options provided, the LEAST appropriate activity for a
nursing assistant would be assisting a post cardiac catheterization client who needs to lie flat to
eat lunch. Because the client needs to eat lying flat, the client is at risk for aspiration.

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 92. ANSWER: D
RATIONALE: The nurse would most appropriately assign the client with emphysema to the LPN.
This client has an airway problem and has the highest priority needs from the other clients
presented in the options. The clients described in option A,B,C can be cared for by the nursing
assistant.

93. ANSWER: D
RATIONALE: Participative leadership suggests a compromise between the authoritarian and the
democratic style. In participative leadership, the manager presents his or her own analysis of
problems and proposals for actions to team members, inviting critique and comments. The
participative leader then analyzes the comments and makes the final decision.

94. ANSWER: C
RATIONALE: The RN must remember that even though a task may be delegated to someone,
the nurse who delegates maintains accountability for the overall nursing care of the client. Only
the tasks, not the ultimate accountability, may be delegated to another. The RN is responsible for
ensuring that competent and accurate care is delivered to the client. Because this is a new
procedure to the LPN, the RN should accompany the LPN and provide guidance in performing
the procedure.

95. ANSWER: C
RATIONALE: Primary nursing is concerned with keeping the nurse at the bedside actively
involved in direct care while planning goal-directed, individualized client care.

96. ANSWER: B
RATIONALE: Case management represents an interdisciplinary health care delivery system to
promote appropriate use of hospital personnel and material resources to maximize hospital
revenues while providing for optimal outcome of care. It manages client care by managing the
client care environment.

97. ANSWER:C
RATIONALE: The functional model of care involves an assembly line approach to client care,
with major tasks being delegated by the charge nurse to individual staff members. Team nursing
is characterized by a high degree of communication and collaboration between members. The
team is generally led by a registered nurse, who is responsible for assessing, developing nursing
diagnosis, planning, and evaluating each client’s plan of care

98. ANSWER: C
RATIONALE: Confrontation is an important strategy to meet resistance head on. Faceto- face
meeting to confront the issue at hand will allow verbalization of feelings, identification of problems
and issues, and the development of strategies to solve the problem.

99. ANSWER: D
RATIONALE: When beginning the change process, the nurse should identify and defines the
problems that needs improvement or correction. This important first step can prevent many future
problems, because if the problem is not correctly identified, a plan for change may be aimed at
the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions
and strategies to implement the change or new system.

100. ANSWER: C
RATIONALE: Option c empowers the charge nurse to assist the staff nurse while trying to identify and
reduce the behaviors that make it difficult for the staff nurse to function

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