A nurse exits the room of a confused client without raising the side
rails on the bed. The failure to raise the side rails would constitute
which element of liability related to
d)Breach of duty
Breach of duty
Breach of duty is failing to meet the standard of care, and in this case, it was the failure to execute and document the use of appropriate safety measures. Causation is the failure to use appropriate safety measures, which results in injury to the client. Duty refers to an obligation to use due care and is defined by the standard of care appropriate for the nurse–client relationship. Damages refers to the actual harm or injury that the client incurs
Which of the following is an area of potential liability for the
nurse? Select all that apply.
a)The nurse documents that the client’s blood pressure has increased from 118/72 to 188/98 and decides to retake the blood pressure in an hour.
b)The nurse fails to document refusal by the client to ambulate following surgery.
c)The nurse administers the client’s preoperative medication after the informed consent is signed.
d)The nurse documents that the client accurately prepared the correct amount of insulin after instruction was given.
e)The nurse notifies the physician of the client’s adverse reaction to a medication.
• The nurse documents that the client’s blood pressure has increased
from 118/72 to 188/98 and decides to retake the blood pressure in an
• The nurse fails to document refusal by the client to ambulate following surgery.
Areas of potential liability would include failure to document refusal by the client to participate in the treatment regimen (such as ambulation after surgery), and failure to assess the client in a timely manner. Waiting an hour to reassess a significant elevation in blood pressure does not meet the standard of care. Reporting a client’s adverse reaction to a medication, administering preoperative medication after the informed consent is signed, and documenting the client’s response to education are nursing behaviors that meet the standard of care
Nurse Practice Acts are examples of which type of laws?
Nurse Practice Acts are statutory laws. Statutory laws must be in keeping with both the federal constitution and the state constitution.
A nursing student administers an overdose of a narcotic to a client
and the client arrests. When discussing the incident with nursing
faculty, which statements, if made by the student, indicate the need
for further teaching?
a)“I realize that I am held to the same standards as a registered nurse.”
b)“I have also put the nursing faculty at risk with my action.”
c)“I am glad I am a student because nursing faculty will be blamed, not me.”
d)“I should have informed you that I felt unprepared for my assignment.”
e)“I cannot be held liable because this is only my second time at this facility.”
• “I am glad I am a student because nursing faculty will be blamed,
• “I cannot be held liable because this is only my second time at this facility.”
A nursing student is responsible and held liable for his or her own actions. The student is responsible for being familiar with the facility’s policies and procedures. The student is held to the same standards as a registered nurse, and puts the clinical faculty at risk and should inform faculty when unprepared for an assignment
The nurse suspecting that a client has an infected surgical wound
should assess for which sign? Select all that apply.
Cardinal signs of infection include redness (heat), swelling, pain, and loss of function. As leukocytes and neutrophils enter the area, exudate made up of fluid, cells, and inflammatory by-products may be released by the wound. Warmth and heat at the site versus coolness are a sign of infection.
The nurse is explaining charting by exception (CBE) to a client who
is curious about documentation. Which statement by the nurse is most
a)"CBE is a relatively new format of documentation in electronic health records."
b)"The benefit of CBE is less time needed on computer charting."
c)"The benefit of CBE is it demonstrates whether high quality care is given."
d)"CBE is the best way to protect against lawsuits."
"The benefit of CBE is less time needed on computer charting."
One of the benefits of CBE is less time needed for documentation. CBE does not always support high quality care and is not the best way to protect against lawsuits since not all data is documented. CBE is not a new format for documentation.
Which patient would the nurse consider the most infectious?
a)A patient who is in the full stage of illness
b)A patient who is in the convalescent period
c)A patient who is in the incubation period
d)A patient who is in the prodromal stage
A patient who is in the prodromal stage
The client is most infectious during the prodromal stage of the illness. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection spreads. The incubation period is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the patient’s general condition. The signs and symptoms disappear, and the person returns to a healthy state.
Which documentation by the nurse best supports the PIE charting
a)States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given
b)Vomiting 250 mL undigested food, antiemetic given, no further vomiting
c)Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea
d)Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg
Vomiting 250 mL undigested food, antiemetic given, no further vomiting
PIE charting includes the Problem, Intervention, and Evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (Problem), antiemetic given (Intervention), no further vomiting (Evaluation).
The nurse is finding it difficult to plan and implement care for a
client and decides to have a nursing care conference. What action
would the nurse take to facilitate this process?
a)The nurse meets with nurses or other health care professionals to discuss some aspect of client care.
b)The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions.
c)The nurse sends or directs someone to take action in a specific nursing care problem.
d)The nurse, along with other nurses, visits clients with similar problems individually at each client’s bedside in order to plan nursing care.
The nurse meets with nurses or other health care professionals to discuss some aspect of client care.
A lead nurse is removing personal protective equipment after dressing
the infected wounds of a client. Which is thehighest
priority nursing action?
a)Make contact between two clean surfaces.
b)Make contact between two contaminated surfaces.
c)Remove the garments that are most contaminated.
d)Handwashing before leaving the client's room.
Handwashing before leaving the client's room.
The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath
A nurse is preparing an operation theater for a surgical procedure.
Which point regarding the principles of surgical asepsis should the
nurse keep in mind when preparing sterilized surgical
a)Any partially uncovered sterile package need not be considered contaminated.
b)A commercially packaged surgical item is not considered sterile if past expiration date.
c)Sterility may not be preserved even when one sterile item touches another sterile item.
d)When a sterile item touches something that is not sterile, it may not be contaminated.
A commercially packaged surgical item is not considered sterile if past expiration date.
When preparing the operation theater for a surgical procedure, the nurse should remember that a commercially packaged surgical item is not considered sterile if it has passed its recommended expiration date. When a sterile item touches an item that is not sterile, then the sterile item is contaminated. If a sterile item touches another sterile item, it is not considered contaminated. A partially uncovered sterile package is considered contaminated.
A nurse is documenting care in a source-oriented record. What action
by the nurse is most appropriate?
a)Use a critical pathway to document the physical assessment.
b)Review the laboratory results under the physician section.
c)Write a narrative note in the designated nursing section.
d)Place the narrative note chronologically after the respiratory therapist's note.
Write a narrative note in the designated nursing section.
Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.
A nurse is using the SBAR technique for hand-off communication when
transferring a client. What are examples of the use of this process?
Select all that apply.
a)A: The nurse presents an assessment of the client to the new nurse.
b)S: The nurse discusses the client’s symptoms with the new nurse in charge.
c)R: The nurse explains the rules of the new facility to the client.
d)B: The nurse gives the background of the client by explaining the client history.
e)S: The nurse handling the transfer describes the client situation to the new nurse.
f)R: The nurse gives recommendations for future care to the new nurse in charge.
• S: The nurse handling the transfer describes the client situation
to the new nurse.
• B: The nurse gives the background of the client by explaining the client history.
• A: The nurse presents an assessment of the client to the new nurse.
• R: The nurse gives recommendations for future care to the new nurse in charge.
Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client’s symptoms with the new nurse in charge as part of the “B” background, not the “S” situation.
How can the nurse researcher obtain information from a client
a)Examine institutional procedures.
b)Interview nursing staff.
c)Study client records.
d)Audit discharge records.
Study client records.
The charge nurse is reviewing SOAP format documentation with a newly
hired nurse. What information should the charge nurse
a)The plan includes interventions, evaluation, and response.
b)Objective data is what the client states about the problem.
c)Abnormal laboratory values are common items that are documented.
d)Subjective data should be included when documenting.
Subjective data should be included when documenting.
Subjective data should be included when using the SOAP format for documentation. Objective data is what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care providers' judgment of the situation, and abnormal lab values would be included in objective data.
The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?
Contact may be either direct or indirect
A nurse is part of a team that will be working in a new orthopedic
unit to determine the most appropriate method for documentation. The
team agrees to initiate the practice of an abbreviated form of
documentation that requires less nursing time and readily detects
changes in client status. Which documentation method would the group
most likely suggest?
a)Problem, intervention, and evaluation note
b)FOCUS data, action, and response note
d)Charting by exception
Charting by exception
The team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation. Narrative notes are time-consuming to write and require much reading to learn about a specific problem. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a FOCUS can be a problem area, but does not need to be.
The nurse receives a verbal order from a physician during an
emergency situation. What actions should be taken by the nurse?
(Select all that apply.)
a)Include V.O. with the physician name on the order.
b)Mark the date and time of the order.
c)Have the physician review and sign the order during the emergency.
d)Record the order on the pharmacy discrepancy sheet.
e)Read back the order.
• Include V.O. with the physician name on the order.
• Mark the date and time of the order.
• Read back the order.
When a verbal order is received during an emergency, the nurse should record the order in the medical record, read back the order, mark the date and time of the order, and record V.O. with the name of the physician who issued the order. After the emergency situation, the physician should review and sign the order.
A nurse documents the following patient data in the patient record
according to the SOAP format: Patient complains of unrelieved pain;
patient is seen clutching his side and grimacing; patient pain
medication does not appear to be effective; Call in to primary care
provider to increase dosage of pain medication or change prescription.
This is an example of what charting method?
b)PIE charting method
d)Focus charting method
The problem-oriented method is organized around a client’s problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically. PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). Focus charting method brings the focus of care back to the client and the client’s concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a client and client care.
A client has requested a translator so that she can understand the questions that the nurse is asking her during the client interview. The nurse knows what is important when working with a client translator?
That translators may need additional explanations of medical terms
When using a translator it is important to remember that the client still comes first. This means that all information is directed at them and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member such as when you are talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across hostile and rude. It is true that even professional translators don't understand all medical terms and may need some clarification at times.
A nurse is taking care of a 66-year-old man post knee surgery. She is
following a clinical pathway that guides the care of this client after
this specific procedure. He is 2 days postoperative and the clinical
pathway states that the nurse should advance his diet. The nurse
enters the client’s room to discuss this order and finds him vomiting
in his wastebasket. A change in client care that deviates from the
clinical pathway is called:
A hospital is changing the format for documentation in an attempt to
decrease the amount of time the nurses are spending on charting. The
new type of charting will require that the nurses document the
significant findings as a narrative note, in a shorthand method using
well-defined standards of practice. Which of the following
best defines this type of charting?
a)Problem, Intervention, Evaluation (PIE) charting
c)Charting by exception (CBE)
Charting by exception (CBE)
Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time. FOCUS charting does not use a problem list of nursing or medical diagnoses, but incorporates many aspects of the client and client care into a FOCUS column. The focus may be a client strength, problem, or need. Problem, Intervention, Evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome, or when a planned intervention is not implemented in the case management model.
Which of the following is not a purpose of the medical
Which of the following masks should the nurse don when caring for a
client with tuberculosis?
c)Low-efficiency particulate air (LEPA)
d)No mask is needed
A school-aged child is admitted to the Emergency Room with the
diagnosis of a concussion following a collision when playing football.
After the collision, the parents state that he was “knocked out” for a
few minutes before recognizing his surroundings. What is the priority
assessment when the nurse first sees the patient?
a)Initiation of a peripheral intravenous (IV) line for fluid administration
b)Assessment of vital signs and respiratory status
c)Assessment of head circumference
d)Evaluation of all of his cranial nerves
Assessment of vital signs and respiratory status
Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than two years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment, and assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined
A 12-year-old is being hospitalized for pneumonia. The nurse receives
the client’s culture and sensitivity report on her tracheal aspirate.
The client is infected with a strain of Streptococcus
pneumonia, which is particularly prone to cause infections, also
referred to as what?
Pathogenicity is an organism's ability to cause infections.
A nurse responds to the call bell and finds another nurse evacuating
the client from the room, which has caught fire. Which action should
the nurse take?
a)Confine the fire.
b)Evacuate the unit.
c)Pull the fire alarm lever.
d)Extinguish the fire.
Pull the fire alarm lever.
The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.
A nurse is caring for a client, age 4 years, who is being treated for
osteomyelitis in his left femur. He is on a 28-day course of IV
vancomycin to be administered daily at 1 p.m. Today is day 3 of
treatment, and the pharmacist asks the nurse to draw a peak vancomycin
level. What would be the most appropriate time to
draw this blood?
b)Wait until day 5 of treatment.
Peak levels are drawn shortly after the drug is administered. The best choice is 3 p.m. because it closely follows the time of infusion, which is when the drug concentration would be highest.
Which action should the nurse perform first after an exposure to a
client’s body fluids?
a)Get tested for both HIV and hepatitis
b)Wash the exposed area with alcohol
c)Wash the exposed area with soap and water
d)Take the post-exposure prophylaxis
Wash the exposed area with soap and water
The first action by the nurse should be to wash the exposed area immediately with warm water and soap. While being tested for HIV and hepatitis and/or taking post-exposure prophylaxis may be appropriate, they would not be the first action by the nurse
What is the primary role of the nurse in the care of clients that
experience domestic violence?
a)Calling the police
b)Providing prompt recognition of the potential or actual threat to safety
c)Identifying health education and counseling measures for the family
d)Serving as a witness in court
Providing prompt recognition of the potential or actual threat to safety
The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.
A nurse is providing care to a client diagnosed with impetigo. The
nurse would institute which type of infection control?
• Contact precautions
Contact precautions are used with organisms that can be transmitted by hand- or skin-to-skin contact (e.g., during client care activities or when touching the client's environmental surfaces or care items) such as with a client with impetigo. Airborne precautions are used to protect against microorganisms transmitted by small-particle droplets that can remain suspended and become widely dispersed by air currents, such as tuberculosis or measles. Droplet precautions are used for microorganisms transmitted by larger-particle droplets which disperse into air currents, such as H. influenzae or M. pneumoniae. Protective isolation is used to prevent infection for people whose body defenses are known to be compromised, such as those who are neutropenic secondary to chemotherapy.
A nurse follows the universal patient compact principles for
partnership when providing care for patients. Which nursing action
does not reflect this philosophy?
a)The nurse allows the patient to review his own medical information.
b)The nurse makes health care decisions for a patient who is uncooperative.
c)The nurse includes the patient as a member of the health care team.
d)The nurse asks for family input from the assigned advocate of the patient.
The nurse makes health care decisions for a patient who is uncooperative.
The National Patient Safety Foundation’s Principles for Partnership represent a concerted effort to demonstrate a health care organization’s commitment to respect the rights of patients and incorporate these beliefs into their mission. The nurse making decisions for an uncooperative patient does not demonstrate these principles. Including the patient and family as a member of the health care team, and allowing the patient to review his own medical information demonstrates these principles.