Rationale: To determine what may and may not be delegated to the various co-workers, the RN making the assignment must take into account several factors: the level of care required by each client, both immediately and in the future; the competencies possessed by the co-workers; and the legal limitations on the practice of those co-workers. Self-administration of insulin and discharge instructions on dressing changes and medications require teaching, a professional responsibility that the RN may not delegate to anyone except another RN. Although the RN might care for a client being discharged, the question tells you that an LPN is available. The RN would be best used to care for the client with more critical or complicated needs. Assigning an RN to a client who is being discharged with no medications is, therefore, incorrect. The client with newly diagnosed leukemia who has a newborn at home is likely to be in need of the skills of an RN in terms of both physiological and psychosocial needs, making this an appropriate assignment.
Rationale: In a situation in which a client has no family members who can provide permission for treatment, the physician may write a DNR order if he or she is reasonably and medically certain that resuscitation would be futile. Therefore the other options are inaccurate.
Rationale: When walking with a client, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the client’s back. The nurse should position the free hand at the shoulder area so that the client may be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet.
Rationale: Confrontation is an important strategy in dealing with resistance. Face-to-face meetings to confront the issue at hand allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Ignoring the resistance does not address the problem. Providing a temporary solution to the resistance by having the registered nurse do all of the computer work and having the LPN perform only specific documentation will not specifically address the concern. Telling the LPN that the noncompliance will be documented in his personnel record may produce additional resistance.
Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the nursing assistant to assist in getting the client into bed. The nurse should then contact the physician and file an incident report.
Rationale: A client’s medical condition is confidential and should never be discussed with anyone other than the client and the client’s healthcare provider. Therefore the nurse must tell the unit secretary that the client’s condition is not to be discussed. The statements “Yes, he does, but be sure not to discuss this with anyone else” and “Yes, that’s why we’ve imposed contact precautions” both confirm the client’s disease and are therefore inappropriate. Responding, “Oh, really? I didn’t see that!” promotes further discussion of the client’s condition and is inappropriate.
Rationale: Privacy is a client’s right to be free from unwanted intrusion into his or her private affairs. Videotaping constitutes an invasion of a client’s privacy, and written permission is required from the client for an action such as photographing or videotaping. Therefore the nurse must explain to the television crew that videotaping is not allowed. The other options are incorrect and constitute invasions of client privacy.
A client with asthma who had shortness of breath during the night
A client scheduled to have a chest x-ray at 9 am
A client scheduled for an echocardiogram at 10 am
A client with pneumonia who is scheduled for discharge home
Rationale: Airway is always the priority, so the nurse would first assess the client with asthma who had shortness of breath during the night. The nurse would next assess the client scheduled for a chest x-ray, because the x-ray is scheduled at 9 am and the nurse would want to gather data about the client before the client leaves the nursing unit. Next the nurse would assess the client scheduled for an echocardiogram at 10 am, and finally the nurse would care for the client scheduled for discharge. The client being discharged will have needs that must be addressed, but there is nothing in the question to indicate that the client must have his or her discharge needs addressed by a specific time.
Rationale: The client who has sustained circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment is to check the peripheral pulses to ensure that circulation is adequate. Although the heart rate and BP would also be assessed, the priority with a circumferential extremity burn is the assessment of peripheral pulses.
A client with a Foley catheter for whom a 24-hour urine collection is in progress
Rationale: The nurse must base assignments on the basis of the skills of the staff member and the needs of the client. The nursing assistant is capable of caring for the client with a Foley catheter for whom a 24-hour urine collection is in progress and the client who requires transport to the radiology department in a wheelchair. The nursing assistant is skilled in such tasks. The client who has just undergone surgery will require specific monitoring in addition to recording of vital signs. Dressing changes and tracheostomy care are not performed by unlicensed personnel.
Rationale: A client may request a DNR order after being given the appropriate information by the physician. Therefore, if a client requests a DNR order the nurse should contact the physician so that the physician may discuss the request with the client. A DNR order should be written, not verbal. The pertinent agency and state guidelines must be followed with regard to when a verbal DNR order is acceptable. Therefore the other options are incorrect.
Rationale: The nurse manager must attend to client assignments first, because client care is the priority. Also, the nursing staff need their assignments so that they may begin client assessments and start delivering client care. The nurse manager should next check the medication supply to ensure that needed medications are available. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next return the phone calls.
Rationale: When a nurse delegates aspects of a client’s care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. Noninvasive interventions such as ambulating a client with a walker may be assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy irrigation should be assigned to a licensed practical nurse (LPN) because these staff members can perform certain invasive procedures. The client who has undergone an arteriogram should be assigned to either an LPN or an RN because these personnel have the knowledge and education to detect changes in the client’s status that require attention.
Rationale: Assignment of tasks must be based the job description of the nursing assistant, the assistant’s level of clinical competence, and state law. Blood transfusions, dressing changes, and ambulation of a client with angina require the skill of a licensed nurse. A client under contact precautions is the most appropriate assignment for the nursing assistant because the nursing assistant is trained to provide hygiene care and to care for clients under specific precautions.
Rationale: Morphine sulfate depresses respiration, so the nurse must monitor the client’s respiratory status closely. Although the incorrect options may be components of the assessment, checking respiratory status is the priority nursing action.
Rationale: Quality documentation and reporting have five important characteristics: factual, accurate, complete, current, and organized. Using an accurate measurement of intake is correct. The use of the word “seems” indicates that the nurse did not know the facts. Using the word “well” is also incorrect, because it does not provide an accurate observation. Likewise, using the word “large” does not provide an accurate measurement.
Rationale: If the client’s condition changes, the DNR order may need to be changed. For this reason, DNR orders require frequent review as specified by state or agency policy. A DNR order may be changed at any time and does not remain in effect for the duration of the client’s hospitalization. The client’s request regarding DNR status is the priority.
Rationale: Nurses must discuss clients in a professional manner and avoid using judgmental language such as “uncooperative” or “difficult.” When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not addressed. Leaving articles about judgmental opinions in the nurse’s report room indirectly addresses the issue. Additionally, the nurse manager cannot ensure that the nursing staff will read the articles. Likewise, reporting the nurses’ comments to administration does not directly address the issue. The best approach that the nurse manager can take is to directly discuss the issue with the staff members. This action is not identified in the options. Therefore, of the options presented, discouraging judgmental comments is the most appropriate way to manage this concern.
Rationale: Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client’s consent, the nurse may be charged with assault. Therefore the nurse is not justified in administering the medication. Battery is any intentional touching without the client’s consent.
Rationale: Intravenous ports must be cleaned with alcohol (or another antiseptic as designated by agency policy) before access. The nurse manager should handle this problem directly with the nurse who is using incorrect technique by first reviewing the nurse’s skills checklist to determine whether this skill has ever been performed by the nurse and validated. There is no information in the question to indicate that an in-service educational session is needed for everyone on the nursing unit. As a part of professional responsibility to maintain quality care, nurses are required to report instances of clinical incompetence.
Rationale: The purpose of standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, across the country. Standards of care include the provision of competent care on the basis of current practice. Methods of treatment are individualized to the care of a specific client. Providing direction of care on the basis of the client’s diagnosis is a matter of medical interventions. New care methods are a matter of research.
Rationale: A case manager is a nurse who assumes responsibility for coordinating a client’s care from the point of admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. A client who exhibits signs of increased intracranial pressure after a craniotomy, indicating a deterioration of the client’s condition, requires immediate follow-up. The descriptions in the other options are expected outcomes.
Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most healthcare institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject.
Rationale: A policy or procedure is a designated plan or course of action to be taken in a specific situation. Written copies of all policies are usually placed in a policy manual that is available in each department or may be available online. Specific unit policies are sometimes referred to as protocols. The policy or protocol for a client who has been raped will describe the physical, psychosocial, and legal responsibilities of the nurse. Calling the nurse in charge during the day shift or asking an LPN or the police officers who brought the client into the ED is inappropriate. If the nurse needs additional information after reviewing the policy or protocol, it would be most appropriate to contact the agency nursing supervisor of the night shift.
Rationale: The RN is responsible for supervising certain procedures performed by an LPN to ensure that client safety is maintained. The deltoid muscle is located in the upper arm area. Administration of an injection into this muscle is done 2 inches below the acromion process (the bony structure on top of the shoulder blade). Therefore the injection is not given in the thigh (vastus lateralis or rectus femoris muscle). The Sims position is not the correct position for an injection into the deltoid muscle. A prone toe-in position is used for injection into the dorsogluteal site or gluteus medius muscle because it will promote internal rotation of the hips, which relaxes the muscle and makes the injection less painful.
Rationale: If the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. The physician must be notified, but this is not the first action. The client would not be instructed to inhale, because this would cause atmospheric air to enter the pleural space. In most situations, clamping of chest tubes is contraindicated. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax, because the air has no escape route.
Rationale: Organizations may be described as having a centralized or decentralized structure in regard to the decision-making process. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals. Conversely, when the decision-making involves a number of individuals, with decisions filtering down to the individual employee, the organization is said to operate in a decentralized fashion.
Rationale: The medication prescription must include the medication name, dose, route of administration, time, and frequency of the administration. The nurse would contact the physician and ask about the route of the medication. The nurse would not prepare the medication or administer it without first checking with the physician. A stat prescription must be administered immediately. Therefore it is inappropriate to plan to have the nurse on the next shift administer the medication.
Rationale: Taking extended lunch breaks is an unacceptable behavior, mainly because the behavior affects client care. The nurse manager must confront the nurse, discuss the behavior, and initiate problem-solving measures to ensure that the behavior does not continue. Ignoring the situation, asking other staff members to cover for the nurse, and documenting the problem in the nurse’s personnel file are all inappropriate because none of these actions will resolve the problem.
Assessing the client’s needs for home supplies and equipment
Coordinating consultations and referrals to facilitate discharge
Establishing a safe and cost-effective plan of care with the client
Rationale: A case manager is a nurse who assumes responsibility for coordinating the client’s care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments.
Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Therefore, the appropriate response is the one that is thorough and complete. Referring the client to the physician places the client’s question on hold. The remaining options are incomplete.
Rationale: The nurse should monitor the client’s heart rate and pulse oximetry during suctioning to assess the client’s tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen. Although the nurse would monitor the client’s pulse oximetry, an improvement would not be expected until the client is reoxygenated. It is not necessary to contact the physician or the respiratory therapist at this time.
A client with pneumonia who is receiving oxygen
A client with diabetes mellitus who requires the administration of NPH insulin before breakfast
A client with a wound requiring dressing changes at 10 am and 2 pm
A client preparing for discharge after surgery
Rationale: Airway is always the priority, so the nurse would assess the client with pneumonia who is receiving oxygen first. The nurse would next care for the client with diabetes mellitus who requires the administration of NPH insulin before breakfast, because the client will not be allowed to consume food or caloric fluids until insulin has been received. Because the client with the wound requires two dressing changes during the shift, this client would be cared for next; the nurse would want to ensure that the changes are done on time. Although the client preparing for discharge would have needs, including education, they are not of immediate importance.
Rationale: Informed consent is a person’s agreement to allow something, such as a treatment, to be performed. A consent form is needed if the problem is a sexually transmitted infection. If the client is a minor, he or she may sign the informed consent in the following situations: if the client is an emancipated minor; if the client is seeking birth control services or is pregnant; if the client is seeking treatment for a sexually transmitted infection, drug or substance abuse, or psychiatric services; or if a court order or other legal authorization has been obtained.
Rationale: Brachytherapy involves the implantation of a sealed radiation source within the targeted tumor tissue. A client who is wearing a solid implant emits radiation as long as the implant is in place; however, the client’s excreta is not radioactive. Pregnant nurses should not care for such clients. There are no contraindications to having a pregnant nurse care for a client under enteric precautions, a client with cancer who is receiving a continuous infusion of intravenous therapy, or a client who requires frequent wound irrigation.
Rationale: Home care provides a variety of support services for the client and family, including assistance with the administration of insulin. For the client who has difficulty drawing insulin into a syringe, the home care nurse would prefill a week’s supply of syringes containing the required dose. These syringes would be placed in the client’s refrigerator for self-administration by the client. A social worker is trained to counsel clients in a variety of areas and may assist with the financial aspects of care. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques. An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding him- or herself with the use of an adaptive device.
Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore it is the nurse’s primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Not all staff members have the education, knowledge, and ability to make judgments about the tasks being performed. The nurse would document that the task was completed, but this would not be done until follow-up had been conducted and outcomes identified. It is not appropriate to assign the tasks that have not been completed to the next nursing shift; this action does not ensure that client needs will be met and also increases the workload for the next shift.
Rationale: An assessment activity is always the first step in the nursing process. Conducting a community survey on school violence addresses assessment of community perceptions. Teaching schoolchildren about the dangers of violence and distributing fliers that identify the cause of school violence are implementation measures. Looking at what other communities are doing is part of the analysis of a variety of assessment data but is not specific to the subject of the question.
Rationale: The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse responds aggressively by stating, “I’m not working overtime today” or “You know how I hate to work overtime.” The statement “I will if you need me, but I am not happy about this” is a passive-aggressive response.
Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. The nursing assistant has been trained to collect and strain urine. The nurse manager would provide instructions to the nursing assistant regarding the task, but the task is within the role description of a nursing assistant. A client scheduled for a cardiac stress test requires preparation for the test, teaching, and postprocedure monitoring. A client scheduled for surgery will require preoperative preparation, including teaching. A client who underwent mastectomy 2 days earlier will need both physiological and psychosocial care, requiring the skills of a licensed nurse.
Rationale: The term authority refers to the official power of an individual to approve or command an action or to see that a decision is enforced. Being responsible for what staff members do, accepting responsibility for the action of others, and carrying legal responsibility for others are not related to the description of a position of authority.
Rationale: A nurse who feels that the assignment is more difficult than the assignments delegated to other nurses on the unit would most appropriately discuss the assignment with the nurse manager of the intensive care unit. This will help the nurse identify the rationale for the assignment or determine whether the assignment is actually more difficult. A nurse would not refuse an assignment. The nurse would not return to the medical care unit, which would constitute client abandonment. Additionally, this action does not address the conflict directly. Telling the nurse manager to call the nursing supervisor is an aggressive action that does not address the conflict directly.
Rationale: A case manager is a nurse who assumes responsibility for coordinating a client’s care from the point of admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. A temperature of 100.6° F in a client with a central venous catheter is an unexpected and unwanted outcome requiring the need for follow-up, because it may indicate the development of an infection. The other options all represent expected outcomes.
A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours
Rationale: When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned the tasks of caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to reinforce teaching regarding the colostomy irrigation (the RN is responsible for the initial teaching) and administering regular insulin in accordance with a sliding scale.
Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made an error or performed an incorrect action or procedure. If a physician’s prescription must be questioned, the nurse should record that clarification regarding the prescription was sought.
Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why.
Rationale: Airway is always the priority, so the nurse would attend to the client who has a condition related to airway first. The other clients do not have conditions related to the airway and represent intermediate priorities.
Rationale: In an emergency situation, if it is impossible to obtain consent from the client or an authorized person, the procedure required to benefit the client or save his or her life may be undertaken without informed consent. In such cases the law assumes that the client would wish to be treated. Contacting the hospital clergy to provide the informed consent and having the nurse sign on behalf of the client with another nurse to witness the signature are both incorrect. Also, having the client undergo mechanical ventilation until his parents can be contacted will delay treatment of a life-threatening injury.
Rationale: CPR is an emergency treatment that is provided without client consent unless a DNR order is part of the client’s record. Calling the nursing supervisor for directions, administering oxygen to the client, and calling the physician are all inappropriate actions that would delay necessary treatment.
Rationale: A nurse serves as a client advocate by protecting the right of the client to be informed and to participate in decisions regarding care. The only option that ensures that the client will be informed of the risks of the surgery is contacting the surgeon and asking that the risks be explained to the client. Telling the client that the risks are minimal is false reassurance. Putting a note on the client’s chart or documenting that the client was not informed about the risks does ensure that the client will be informed.
Rationale: The nurse should document task completion and client information throughout the day. Allowing time for unexpected tasks, prioritizing needs and tasks, and gathering supplies before beginning a task are all components of time management.
Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client’s decision. Therefore the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate and represent violations of the client’s rights. Telling the client that the physician will be informed of the refusal of care is a threatening action on the nurse’s part.
Have some similarity to policies and procedures
Are authoritative statements that describe a common or acceptable level of client care or performance
Rationale: Standards of care are authoritative statements that describe a common or acceptable level of client care or performance. They bear some similarity to policies and procedures. Therefore standards of care define professional practice. The American Nurses Association has formulated general standards and guidelines for nursing practice. They are general in nature and apply across the nation.
Crackles were heard in the lower lung lobes bilaterally on auscultation.
Rationale: A case manager is a nurse who assumes responsibility for coordinating a client’s care from the point of admission through, and after, discharge. This nurse initiates a nursing plan of care, care map, or clinical pathway as appropriate to guide care, evaluating and updating the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. Crackles heard in the lower lobes of the lungs in a client with heart failure are an unexpected and unwanted outcome requiring follow-up because they could indicate the development of pulmonary edema. The notations made for the other clients listed represent expected outcomes.
Rationale: When a staff member reports to work in a state of alcohol intoxication, the nurse notes the signs objectively and asks a second person to validate these observations. The nurse also contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are symptoms of intoxication. Client safety is the primary concern. The intoxicated nurse is removed from the situation, confronted briefly and firmly about the behavior, and sent home to rest and recuperate. The incident is recorded and the nurse describes the observations, states the action taken, indicates future plans, and has the staff member sign and date the memo of the recorded incident after returning to work. Refusal to sign and date the memo should be noted by the charge nurse and a witness. Neither asking the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to administer medications removes the staff member from the client care area, jeopardizing the client’s safety. Asking the staff member how much alcohol she has consumed is confrontational and irrelevant.
“It carries legal implications for task performance.”
“You must answer for the care that you ask others to complete.”
“It refers to the process of answering or being responsible for what occurs.”
Rationale: Accountability, the process of answering or being responsible for what occurs, carries legal implications for task performance. Accountability cannot be delegated; one is responsible for one’s own actions and must answer for the care given, as well as for the care one asks others to complete.
Rationale: A client scheduled for hemodialysis has needs that must be met before the procedure. The nurse must ensure that the client is physically and emotionally ready for the treatment, which may take as long as 5 hours. Before the treatment, the nurse must assess the client, including looking for fluid overload by checking the client’s weight and lung sounds. The nurse must also assess the client’s predialysis vital signs and the results of laboratory tests for comparison in the postdialysis period. Although the clients described in the other options have needs, they are not immediate. A client scheduled for a nuclear scanning procedure at 10 am may require reinforcement of information about the procedure and will need to increase fluid intake before the procedure. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am may require pain medication, but the medication should be administered approximately 30 minutes before the hydrotherapy. A client scheduled for contrast CT at noon may require reinforcement of information about the procedure and may need to drink a special contrast preparation just before the procedure.
Rationale: A client who complains of severe pain may need realignment or may have traction weights that are too heavy. The nurse would first realign the client and then, if this is ineffective, call the physician. Asking the client to wiggle her toes serves no useful purpose. The nurse never removes traction weights unless this has been specifically prescribed by the physician. The client should be medicated only after an effort has been made to determine and treat the cause of her pain.
Rationale: To help prevent aspiration, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Checking when a feeding or medication was last given and checking the client’s apical pulse are not directly related to the subject of the question.
Rationale: An organizational chart depicts and communicates how activities are arranged, how authority relationships are defined, and how communication channels are established. Understanding the organization’s reason for existence, geographical area, and the beliefs and values of the organization are all components of the organization’s mission statement.
Rationale: An individual who is at least 18 years old may make an anatomical gift of all or part of the human body. The gift must be made in writing and signed by the donor. If the client cannot sign, the document must be signed by another individual and two witnesses. The physician is informed of the client’s wishes and the client may wish to speak to a chaplain, but the specific procedure requires a written document signed by the client. The family of a deceased client may be asked about organ donation, but this is not the procedure when a living person wishes to become a donor.
Rationale: Common negligent acts include medication errors that result in injury to the client; intravenous therapy errors resulting in infiltrations or phlebitis; burns caused by equipment, bathing, or spills of hot liquids and foods; falls resulting in an injury; failure to use aseptic technique where required; failure to give report or giving an incomplete report to an oncoming shift; failure to adequately monitor a client’s condition; and failure to notify a physician of a significant change in a client’s condition. Using clean gloves is a negligent act. The nurse would use sterile gloves to change a dressing over broken skin.
Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. Staff do not have the power to reprimand and punish or make decisions regarding scheduling or the nursing unit.
Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients.
Rationale: Confrontation is an important strategy for addressing resistance by a staff member who is complaining about an agency protocol. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings and identification of problems and issues, and give the nurse manager the opportunity to develop strategies to solve the problem. Ignoring the complaints and avoiding assigning the nurse mandatory overtime are inappropriate strategies that do not address the problem. Providing a positive reward system might provide a temporary solution to the resistance but will not specifically address the problem.
Rationale: All organizations have a purpose or reason for existing. This purpose is often expressed in the form of a mission statement. The mission statement outlines what the organization plans to accomplish. Sometimes mission statements incorporate statements of philosophy (beliefs), purpose, and goals or objectives into a single statement; other times the philosophy, purposes, and goals are addressed in addition to the mission statement. These statements serve as a benchmark against which an organization’s performance may be evaluated. The mission statement does not describe the benefits available to the client; this is usually done by the human resources department. The rules of the organization are identified in policies and procedures, which are usually maintained in manuals kept in the nursing units or online.
Rationale: An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding him- or herself with the use of an adaptive device. Home care provides a variety of support services for the client and family, but the specific assistance needed for this client would be provided by the occupational therapist. A social worker is trained to counsel clients in a variety of areas and may assist with the financial aspects of care. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques.
Rationale: The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. The affected client also complains that pain during passive motion is greater than that during active motion. The nurse must notify the physician immediately. The other options are incorrect because they delay necessary interventions.
Rationale: Actual removal of a chest tube is the duty of a physician. Therefore the nurse would first inform the physician that this is not a nursing procedure. If the physician insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agency’s policies and procedures may permit an advanced practice nurse (a nurse with a master’s degree in a specialized area of nursing) to remove a chest tube. However, there is no information in the question to indicate that the nurse is an advanced practice nurse.
Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a nursing assistant would be assisting a client with dysphagia with eating because of the risk of complications such as choking and aspiration. The remaining three situations include no data to indicate that these tasks carry any unforeseen risk.
Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that is needed by others. Reward power is based on the ability to be able to grant rewards and favors. Coercive power is based on fear and the ability to punish. Referent power results from followers’ desire to identify with a powerful person.
Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy.
Rationale: Telephone prescriptions involve a physician’s dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription clearly and precisely to the physician. The nurse then writes the prescription on the physician’s prescription sheet. Under no circumstances should the nurse try to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. The nurse must call the physician who gave the telephone prescription and clarify the prescription.
Rationale: A nurse practice act regulates the licensure and practice of nursing. Nurse practice acts describe in general terms what constitutes nursing practice. Actions that are considered unprofessional conduct are usually identified. Guidelines for procedures and policies are formulated by the specific healthcare agency. The healthcare policies of the state in question are not identified in a nurse practice act.
Rationale: When a nurse delegates aspects of a client’s care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. A client receiving oxygen who requires pulse oximetry monitoring and respiratory treatments should be assigned to the LPN, because this staff member can perform these tasks and is competent to note changes in the client’s condition. Feeding a client, turning and repositioning a client, and assisting with hygiene measures, all noninvasive interventions, may be assigned to a nursing assistant.
Rationale: The first thing the nurse who observed the error should do is ask the nurse whether she intends to report the error. As means of helping ensure client safety, all errors must be reported to the physician, but this is not the initial action. The client also needs to be assessed immediately. An incident report should be completed by the nurse who discovered the error (the nurse who changed the intravenous solution). The appropriate documentation also must be made in the client’s record by the nurse who discovered the error. If the nurse who discovered the error indicates that the error will not be reported, it may be necessary for the other nurse to contact the supervisor.
Rationale: Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Contacting the physician about the client’s request that complementary therapies be used to relieve pain is an example of fidelity. Respect for a person’s autonomy, or independence, involves respecting that person’s right to determine his or her own course of action. Allowing a client to decide when he or she would like to have daily hygiene care is an example of respecting a client’s autonomy. Beneficence is taking action to help others. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion is an example of beneficence. Although insertion of an intravenous catheter might cause discomfort, the benefits of receiving the transfusion outweigh the temporary discomfort. Justice refers to fairness and equity; in the healthcare arena, this involves ensuring fair allocation of resources, such as nursing care, to all clients. Providing complete information regarding treatment options to each client with a cancer diagnosis is an example of justice.
Rationale: The nurse should document relevant information in an accurate, complete, and objective form. Noting the client had an allergy to cefazolin sodium does not identify objective data. Assuming that the client is allergic to cefazolin sodium because of warm and flushed skin makes an interpretation about the occurrence. Documenting that the physician was notified because the client developed a rash while receiving the medication identifies accurate data, but is incomplete.
Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into the sterile basin reflects evidence-based practice because this action cleans the lip of the bottle, thus preventing the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Encouraging a client with a stroke to consume thin liquids and foods could cause harm because of the risk for choking; instead, such a client should receive thickened liquids. A dislodged radiation implant should be picked up with the use of long-handled forceps, not gloved hands, to be placed in a lead container to minimize radiation exposure. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab recontaminates the stick site.
Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. Oral care may be delegated to a nursing assistant. The nurse would provide instructions to the nursing assistant regarding the task, how to adapt the procedure for the client at risk for aspiration, and the signs of complications that must be reported immediately (e.g., bleeding gums, excessive coughing). A client who has just undergone cardiac catheterization requires monitoring for complications, and a client scheduled for liver biopsy requires preparation for the test and client teaching. A client who is getting up to ambulate for the first time after surgery is at risk for orthostatic hypotension and should be assisted by a licensed nurse.
Rationale: A social worker is trained to counsel clients in a variety of areas. Counseling services may include providing emotional support for clients and families during severe and terminal illnesses, arranging placement in extended care facilities, and locating financial resources. Clergy (pastoral care) offer spiritual support and guidance to clients and families. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques. An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding him- or herself with the use of an adaptive device.
Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action.
Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits.
Rationale: When an employee demonstrates an unacceptable level of absenteeism, the nurse must first remind the employee of the employment standards of the agency. Sometimes an employee does not know or has forgotten the existing standards, and a reminder with no threats or discipline is all that is needed. When the oral reminder does not result in a change in behavior, the reminder should be placed in writing. If the written reminder fails, the employee should be granted a day of decision to determine whether to accept the standards for work attendance. Pay may be given for this day (depending on the agency protocol) so that it is not interpreted as punishment, and the employee must return to work with a written decision. If the employee decides not to adhere to standards, her employment with the agency is terminated. Reporting the employee to administration, documenting the employee’s behavior in her personnel file, and telling the employee that she will be fired if she calls in sick again are not appropriate initial actions.
Rationale: The care map is a type of critical pathway that incorporates expected day-to-day client outcomes and those anticipated at discharge or at the end of a treatment phase. It outlines clinical assessments, treatments and procedures, dietary interventions, activity and exercise therapies, client education, and discharge planning. It may identify nursing diagnoses but is developed by members of all disciplines that normally care for the particular client type and is used by all members of the interdisciplinary team. Continuity of care can be achieved with the use of a care map.
Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Pulmonary tuberculosis is a respiratory infection that is transmitted to others by way of the airborne route. The door to the client’s room must be kept closed to prevent the transmission of the infection via the airborne route. The remaining options do not reflect evidence-based practice. An N95 or HEPA respirator (not a surgical mask) must be worn by the nurse on entering the room. It is not necessary for the client to wear a mask. Airborne precautions require the use of a private room.
Rationale: The nurse may not violate a family’s request regarding the client’s treatment plan. A “slow code” is not acceptable, and the nurse should state this to the physician. The definition of a “slow code” varies among healthcare facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are therefore inappropriate.
Rationale: A client undergoing a chest x-ray must remove all metal objects to help prevent artifacts on the x-ray. If the client expresses concern about removing the medal, the nurse should help the client pin the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. The nurse should also alert staff in the radiology department that this has been done. If the client is expressing concern about removing the medal, asking the client to remove it or leave it with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the likelihood that the medal and chain will be lost.
Rationale: The physician should write all prescriptions. Verbal prescriptions are not recommended, because they increase the risk for error. If a verbal prescription is necessary, such as during an emergency, it should be written and signed by the physician as soon as possible, usually within 24 hours. The nurse must follow agency policies and procedures regarding verbal prescriptions. The appropriate nursing action would be to ask the physician to write the prescription in the client’s record before leaving the nursing unit. Changing the solution in keeping with the verbal prescription and contacting the supervisor to obtain permission to accept the verbal prescription each imply that the nurse accepts the verbal prescription. Telling the physician that the prescription will not be implemented until it is documented in the client’s record delays necessary treatment.
Taking the break in the staff lounge located on the nursing unit
Rationale: The RN is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. A nursing assistant should never be asked to perform any activity that he or she is not trained for. This includes such activities as administering medications; assessing, monitoring, or evaluating the client; and making decisions about contacting a physician.
Current diagnosis and any secondary diagnoses
Results of laboratory studies conducted that day
Client response to treatments implemented that day
Rationale: A change-of-shift report ensures continuity of care among nurses caring for a client and informs the nurse on the next shift about the client’s needs and priorities for care. It may be given written, orally, by audiotape, or while the nurses are walking rounds at a client’s bedside. The report should describe the client’s health status, current and secondary diagnoses, results of laboratory or diagnostic studies done that day, and the client’s response to treatments implemented that day. The client’s family history does not need to be described in a change-of shift report, and doing so would take time. If such information is needed by the oncoming nurse, it may be obtained from the client’s medical record. There is no useful reason for describing a routine procedure; this would also take time, and the information is available in the agency procedure manual.
Rationale: When a conflict arises, it is most appropriate to try resolving the conflict directly. In this situation, the nurse has tried to explain why she is uncomfortable with the physician’s request but has been unable to resolve the conflict. The nurse would then most appropriately use organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the physician or seek assistance from the nursing supervisor. Fulfilling the physician’s request and writing the prescriptions in the clients’ charts ignores the issue. Reporting the physician to the chief of medicine is inappropriate, because the nurse should use the appropriate organizational channels of communication to resolve the conflict. Stating, “I don’t care whether you report me. I am not writing your prescriptions” is an inappropriate statement and will result in further conflict between the nurse and physician.
A client with heart failure whose condition has been stable since the administration of furosemide (Lasix)
A client with gastroenteritis and diarrhea
A client with suspected gallbladder disease who is scheduled for an ultrasound of the abdomen
A client with a herniated disc who is scheduled to be discharged today
Rationale: The nurse would first assess the client with a cardiac problem. Even though the client’s condition is stable, this client has received medication for stabilization and requires continued close monitoring. After this assessment, the nurse would assess the client with gastroenteritis for signs of fluid volume deficit (dehydration). The nurse would next assess the client scheduled for the ultrasound to ensure that this client understands the reason for the test. Finally the nurse would assess the client preparing for discharge to determine the need for reinforcement of home care instructions.
Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidence-based practice, because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted.
Rationale: Battery is any intentional touching of a client without the client’s consent. Such contact may be harmful to the client or it may merely be offensive to the client’s dignity. If a nurse discovers that battery of a client has occurred, the nurse should report the situation to the nursing supervisor. Telling the client that the nurse did the right thing in giving the enema is incorrect, because the other nurse has violated the client’s rights. Confronting the nurse and telling her that she is going to be charged with battery would likely result in unnecessary conflict. Although the physician may need to be notified, the nurse should first report the situation to the nursing supervisor.
Rationale: Informed consent is the authorization by a client or a client’s legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client’s part, the nurse has the obligation to contact the surgeon. Telling the client that she needs to ask questions before signing the consent for surgery is incorrect. Although the client should be thoroughly informed before signing consent, the client has the right to ask questions thereafter. It is the surgeon’s responsibility to explain the procedure, and, if the client wishes, she has the right to cancel the surgical procedure. Although these are correct statements, they are not the most appropriate and do not address the client’s concerns. Additionally, they do not address the legal ramifications associated with informed consent.
Rationale: A nurse must follow a physician’s prescription unless he or she believes that the prescription is in error or that it would harm the client. If a prescription is found to be incorrect or harmful, further clarification from the physician is necessary. If the physician confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact the nursing supervisor. The nurse should not continue transcribing the prescription or ask another nurse to implement the prescription. The nurse might ask the client about the medication and the dose taken at home but would not administer the medication.
Rationale: Unless a client consents, a nurse may not disclose confidential information to anyone else. Therefore the appropriate response is to tell the client’s wife that she will have to discuss the test with the client. Likewise, a client’s medical record is confidential and cannot be given to the wife for reading. Telling the client’s wife that the radiology department is unclear as to what test has been prescribed is inappropriate. The nurse must not place the responsibility or accountability for a prescribed test on another department.
Rationale: For adequate absorption, levothyroxine must be administered with water on an empty stomach as soon as the client awakens and at least 1 hour apart from other fluids (e.g., coffee or tea), food, and other medications. Therefore this medication should be administered first. Atorvastatin (Lipitor), an HMG-CoA reductase inhibitor used to lower cholesterol, is administered at bedtime because cholesterol synthesis is increased during the night. Zolpidem, a benzodiazepine-like medication used to enhance sleep, is administered at bedtime. Ferrous sulfate is an iron supplement that is administered with water between meals.
Rationale: For the client assignment presented, the RN would plan to care for the client who is scheduled for surgery at 1 pm first. Several items need to be addressed before surgery, including client preparation (physical and emotional) and physician prescriptions, all of which will take time. Also, many times the operating room will make late changes in the schedule, depending on room and physician availability, and will request an earlier surgical time. Therefore it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to a client. The needs of the client who is independent and the client scheduled for physical therapy later in the morning are not high priorities.