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Leadership Management - Ethical/Legal

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  ID
Quiz 256732
  Card Set
Leadership
  Management -
iOS Ethical/Legal
 
Description
  Ethical/Legal
Android
Updated
 
4/19/2014,
  8:50:16 PM
More Show Answers

1. The nurse hears a client calling out for help, hurries down the hallway to
the client's room, and finds the client lying on the floor. The nurse performs
an assessment, assists the client back to bed, notifies the health care
provider of the incident, and completes an incident report. Which statement
should the nurse document on the incident report?
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get out of bed.

3. The client was found lying on the floor.

2. A client is brought to the emergency department by emergency medical

services (EMS) after being hit by a car. The name of the client is unknown,
 and the client has sustained a severe head injury and multiple fractures and
is unconscious. An emergency craniotomy is required. Regarding informed
consent for the surgical procedure, which is the best action?
1. Obtain a court order for the surgical procedure.
2. Ask the EMS team to sign the informed consent.
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family.

3. Transport the victim to the operating room for surgery.

3. The nurse arrives at work and is told to report (float) to the intensive care
unit (ICU) for the day because the ICU is understaffed and needs additional
nurses to care for the clients. The nurse has never worked in the ICU. The
nurse should take which action first?
1. Call the hospital lawyer.
2. Refuse to float to the ICU.
3. Call the nursing supervisor.
4. Identify tasks that can be performed safely in the ICU.

4. Identify tasks that can be performed safely in the ICU.

4. The nurse who works on the night shift enters the medication room and
finds a co-worker with a tourniquet wrapped around the upper arm. The co-
worker is about to insert a needle, attached to a syringe containing a clear
liquid, into the antecubital area. Which is the most appropriate action by
the nurse?
1. Call security.
2. Call the police.
3. Call the nursing supervisor.
4. Lock the co-worker in the medication room until help is obtained.

3. Call the nursing supervisor.

5. A hospitalized client tells the nurse that a living will is being prepared and
that the lawyer will be bringing the will to the hospital today for witness
signatures. The client asks the nurse for assistance in obtaining a witness to
the will. Which is the most appropriate response to the client?
1. "I will sign as a witness to your signature."
2. "You will need to find a witness on your own."
3. "Whoever is available at the time will sign as a witness for you."
4. "I will call the nursing supervisor to seek assistance regarding your
request."

4. "I will call the nursing supervisor to seek assistance regarding your
request."

6. The nurse has made an error in a narrative documentation of an assessment

 finding on a client and obtains the client's record to correct the error. The
nurse should take which action to correct the error?
1. Documenting a late entry into the client's record
2. Trying to erase the error for space to write in the correct data
3. Using whiteout to delete the error to write in the correct data
4. Drawing one line through the error, initialing and dating, and then
documenting the correct information

4. Drawing one line through the error, initialing and dating, and then
documenting the correct information

7. Which identifies accurate nursing documentation notations? Select all that

apply.
1. The client slept through the night.
2. Abdominal wound dressing is dry and intact without drainage.
3. The client seemed angry when awakened for vital sign measurement.
4. The client appears to become anxious when it is time for respiratory
treatments.
5. The client's left lower medial leg wound is 3 cm in length without
redness, drainage, or edema.
o 1. The client slept through the night.
o 2. Abdominal wound dressing is dry and intact without drainage.
o 5. The client's left lower medial leg wound is 3 cm in length
without redness, drainage, or edema.
8. A nursing instructor delivers a lecture to nursing students regarding the
issue of client's rights and asks a nursing student to identify a situation that
represents an example of invasion of client privacy. Which situation, if
identified by the student, indicates an understanding of a violation of this
client right?
1. Performing a procedure without consent
2. Threatening to give a client a medication
3. Telling the client that he or she cannot leave the hospital
4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission

9. Nursing staff members are sitting in the lounge taking their morning break.
An unlicensed assistive personnel (UAP) tells the group that she thinks that
the unit secretary has acquired immunodeficiency syndrome (AIDS) and
proceeds to tell the nursing staff that the secretary probably contracted the
disease from her husband, who is supposedly a drug addict. Which legal
tort has the UAP violated?
1. Libel
2. Slander
3. Assault
4. Negligence
 2. Slander

10. An 87-year-old woman is brought to the emergency department for

treatment of a fractured arm. On physical assessment, the nurse notes old
and new ecchymotic areas on the client's chest and legs and asks the client
how the bruises were sustained. The client, although reluctant, tells the
nurse in confidence that her son frequently hits her if supper is not prepared
on time when he arrives home from work. Which is the most
appropriate nursing response?
1. "Oh, really. I will discuss this situation with your son."
2. "Let's talk about the ways you can manage your time to prevent this from
happening."
3. "Do you have any friends that can help you out until you resolve these
important issues with your son?"
4. "As a nurse, I am legally bound to report abuse. I will stay with you
while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you
while you give the report and help find a safe place for you to stay."

11. The nurse calls the heath care provider (HCP) regarding a new medication
prescription because the dosage prescribed is higher than the recommended
dosage. The nurse is unable to locate the HCP, and the medication is due to
be administered. Which action should the nurse take?
1. Contact the nursing supervisor.
2. Administer the dose prescribed.
3. Withhold the medication until the HCP can be contacted.
4. Administer the recommended dose until the HCP can be located.

1. Contact the nursing supervisor.

12. The nurse employed in a hospital is waiting to receive a report from the
laboratory via the facsimile (fax) machine. The fax machine activates and
the nurse expects the report, but instead receives a sexually oriented
photograph. Which is the most appropriate nursing action?
1. Call the police.
2. Cut up the photograph and throw it away.
3. Call the nursing supervisor and report the incident.
4. Call the laboratory and ask for the individual's name who sent the
photograph.

3. Call the nursing supervisor and report the incident.

13. The nurse manager has implemented a change in the method of the nursing
delivery system from functional to team nursing. An unlicensed assistive
personnel (UAP) is resistant to the change and is not taking an active part
in facilitating the process of change. Which is the best approach in dealing
 with the UAP?
1. Ignore the resistance.
2. Exert coercion on the UAP.
3. Provide a positive reward system for the UAP.
4. Confront the UAP to encourage verbalization of feelings regarding the
change.

4. Confront the UAP to encourage verbalization of feelings regarding

the change.

14. The nurse manager is observing a new nursing graduate caring for a burn
client in protective isolation. The nurse manager intervenes if the new
nursing graduate planned to implement which unsafe component of
protective isolation technique?
1. Using sterile sheets and linens
2. Performing strict handwashing technique
3. Wearing gloves and a gown only when giving direct care to the client
4. Wearing protective garb, including a mask, gloves, cap, shoe covers,
gowns, and plastic apron

3. Wearing gloves and a gown only when giving direct care to the client

15. A client admitted voluntarily for treatment of an anxiety disorder demands

to be released from the hospital. Which action should the nurse
take initially?
1. Contact the client's health care provider (HCP).
2. Call the client's family to arrange for transportation.
3. Attempt to persuade the client to stay "for only a few more days."
4. Tell the client that leaving would likely result in an involuntary
commitment.

1. Contact the client's health care provider (HCP).

16. The nurse is providing care to a client admitted to the hospital with a
diagnosis of acute anxiety disorder. The client says to the nurse, "I have a
secret that I want to tell you. You won't tell anyone about it, will you?"
What is the most appropriate nursing response?
1. "No, I won't tell anyone."
2. "I cannot promise to keep a secret."
3. "It depends on what the secret is about."
4. "If you tell me the secret, I may need to document it."

2. "I cannot promise to keep a secret."

17. The nurse employed in a mental health clinic is greeted by a neighbor in a

local grocery store. The neighbor says to the nurse, "How is Carol doing?
She is my best friend and is seen at your clinic every week." Which is
 the most appropriate nursing response?
1. "I cannot discuss any client situation with you."
2. "If you want to know about Carol, you need to ask her yourself."
3. "Only because you're worried about a friend, I'll tell you that she is
improving."
4. "Being her friend, you know she is having a difficult time and deserves
her privacy."

1. "I cannot discuss any client situation with you."

18. The nurse calls security and has physical restraints applied when a client
who was admitted voluntarily becomes both physically and verbally
abusive while demanding to be discharged from the hospital. Which
represents the possible legal ramifications for the nurse associated with
these interventions? Select all that apply.
1. Libel
2. Battery
3. Assault
4. Slander
5. False imprisonment
o 2. Battery
o 3. Assault
o 5. False imprisonment
19. Which statement demonstrates the bestunderstanding of the nurse's role
regarding ensuring that each client's rights are respected?
1. "Autonomy is the fundamental right of each and every client."
2. "A client's rights are guaranteed by both state and federal laws."
3. "Being respectful and concerned will ensure that I'm attentive to my
clients' rights."
4. "Regardless of the client's condition, all nurses have the duty to respect
client rights."

3. "Being respectful and concerned will ensure that I'm attentive to my

clients' rights."

20. The nurse is caring for a client who was involuntarily hospitalized and is
scheduled for electroconvulsive therapy. The nurse notes that an informed
consent has not been obtained for the procedure. Based on this information,
what is the nurse's best determination?
1. The informed consent does not need to be obtained.
2. The informed consent should be obtained from the family.
3. The informed consent needs to be obtained from the client.
4. The health care provider will provide the informed consent.

3. The informed consent needs to be obtained from the client.

21. A client has refused to eat more than a few spoonfuls of breakfast. The
health care provider has prescribed that tube feedings be initiated if the
client fails to eat at least half of a meal because the client had been losing
weight for the previous 2 months. The nurse enters the room, looks at the
tray, and states, "If you don't eat any more than that, I'm going to have to
put a tube down your throat and get a feeding in that way." The client
begins crying and tries to eat more. Based on the nurse's actions, the nurse
may be accused of which violation?
1. Assault
2. Battery
3. Slander
4. Invasion of privacy

1. Assault

22. A client has refused to eat more than a few spoonfuls of breakfast. The
health care provider has prescribed that tube feedings be initiated if the
client fails to eat at least half of a meal because the client has been losing
weight for 2 months. The nurse enters the room, looks at the tray, and
states, "If you don't eat any more than that, I'm going to have to put a tube
down your throat and get a feeding in that way." The client begins to cry
and tries to eat more. Based on the nurse's actions, the nurse may be
accused of which legal tort?
1. Assault
2. Battery
3. Slander
4. Invasion of privacy

1. Assault

23. A nursing instructor asks the nursing student to describe the definition of a
critical path. Which statement, if made by the student, indicates a need for
further teaching regarding critical paths?
1. "They are developed based on appropriate standards of care."
2. "They are nursing care plans and use the steps of the nursing process."
3. "They are developed through the collaborative efforts of members of the
health care team."
4. "They provide an effective way for monitoring care and for reducing or
controlling the length of hospital stay for the client."

2. "They are nursing care plans and use the steps of the nursing
process."

24. The nurse witnesses an automobile crash on a highway and stops to provide
assistance to the victim. The nurse notes that the client has sustained a head
injury and a compound fracture to the left leg. The nurse provides the
appropriate care before transport of the victim to the hospital by
 ambulance. The client develops a severe bone infection at the site of the
fracture that requires amputation of the leg and files suit against the nurse
who provided care at the scene of the crash. Which is accurate regarding
the nurse's immunity from this suit?
1. The Good Samaritan Law will protect the nurse.
2. The Good Samaritan Law will not protect the nurse.
3. The Good Samaritan Law protects laypersons but not professional health
care providers (HCP).
4. The Good Samaritan Law will provide immunity from the suit, even if
the nurse has accepted compensation for the care provided.

1. The Good Samaritan Law will protect the nurse.

25. A 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 during the change process. Whichprimary technique should
the nurse use in implementing this change?
1. Introduce the change gradually.
2. Use coercion to implement the change.
3. Manipulate the participants in the change process.
4. Confront the individuals involved in the change process.

1. Introduce the change gradually.

26. The registered nurse (RN) is observing a licensed practical nurse (LPN)
who is caring for a client with a uterine tumor who had a vaginal
hysterectomy. The RN should intervene if the RN notes the LPN
performing which action?
1. Assisting the client to ambulate
2. Elevating the knee gatch on the client's bed
3. Performing range-of-motion exercises to the client's legs
4. Removing the antiembolism stockings during morning care

2. Elevating the knee gatch on the client's bed

27. A registered nurse (RN) is supervising a licensed practical nurse (LPN)

administering an intramuscular (IM) injection of iron to an assigned client.
The RN would intervene if the LPN is observed performing which action?
1. Using a Z-track method for injection
2. Massaging the injection site after injection
3. Preparing an air lock when drawing up the medication
4. Changing the needle after drawing up the dose and before injection

2. Massaging the injection site after injection

28. The nurse employed in a surgical unit in a hospital arrives at work and is
told to report (float) to the pediatric unit for the day because the unit is
 understaffed and the census on the pediatric unit is unusually high. The
nurse has never worked in the pediatric unit and does not want to float to
pediatrics. Which action by the nurse is appropriate?
1. Refuse to float to pediatrics.
2. Convince another nurse to float to the pediatric unit.
3. Tell the supervisor that she needs to go home because of illness.
4. Call the nursing supervisor to discuss the request to report to pediatrics.

4. Call the nursing supervisor to discuss the request to report to

pediatrics.

29. The nurse is acting in the role of client advocate in which situations? Select
all that apply.
1. Promoting client comfort
2. Demonstrating mutual respect for all nurses
3. Questioning health care provider prescriptions
4. Supporting a client decision regarding a health care choice
5. Speaking at a continuing education offering in the community
o 1. Promoting client comfort
o 3. Questioning health care provider prescriptions
o 4. Supporting a client decision regarding a health care choice
30. A case manager is reviewing the records of the clients in the nursing unit.
Which occurrence, if noted in a client's record, would the nurse identify as
a positive variance?
1. A client is performing colostomy irrigations.
2. The client with a leg ulcer is demonstrating signs of wound healing.
3. A postoperative client is discharged home 1 day earlier than expected.
4. The client with diabetes mellitus is administering insulin injections
appropriately.

3. A postoperative client is discharged home 1 day earlier than expected.

31. A nurse calls a client's health care provider (HCP) to report that the client,
who has heart failure, is demonstrating increased wheezes on lung
auscultation and dyspnea. The HCP is in a hurry because of involvement in
a critical care situation in the hospital emergency department and gives the
nurse a telephone prescription for furosemide (Lasix). Afterward the nurse
realizes that the route of the medication is unclear. Which would be the
appropriate action by the nurse?
1. Call the HCP who gave the telephone prescription and clarify the
prescription.
2. Call the nursing supervisor for assistance in determining the route of the
medication.
3. Administer the medication by the intravenous route because this route
usually is used for clients with heart failure.
4. Administer the medication by the oral route, and clarify the prescription
once the HCP has finished addressing the critical care issue in the
 emergency department.

1. Call the HCP who gave the telephone prescription and clarify the
prescription.

32. The nurse is supervising a nursing student who is delivering care to a client
with a burn injury to the chest. Nitrofurazone is prescribed to be applied to
the site of injury. The nurse should intervene if the student planned to
implement which action to apply the medication?
1. Wash the burn site.
2. Apply 1/16-inch film directly to the burn sites.
3. Apply the medication with a sterile gloved hand.
4. Apply saline-soaked dressings over the medication.

4. Apply saline-soaked dressings over the medication.

33. A health care provider (HCP) asks the nurse to discontinue tube feeding in
a client who has a terminal condition. The HCP tells the nurse that the
request was made by the client's spouse and children. What should the
nurse check for first before carrying out the prescription?
1. Court approval to discontinue the treatment
2. Approval by the institutional ethics committee
3. A written prescription by the HCP to remove the tube
4. Authorization by the family to discontinue the treatment

4. Authorization by the family to discontinue the treatment

34. After initial assessment the nurse determines the need to place a restraint on
a client. The client refuses application of the restraint. What is
the best nursing action for this client?
1. Apply the restraint anyway.
2. Contact the health care provider (HCP).
3. Compromise with the client and then apply the restraint.
4. Medicate the client with a sedative, and then apply the restraint.

2. Contact the health care provider (HCP).

35. While eating lunch in the hospital cafeteria, a nursing student overhears
two nurses talking about a client. The student understands which fact about
confidentiality?
1. Talking about clients in public places is a violation of the client's
confidentiality.
2. The client's rights to confidentiality do not apply to the break time of
employees.
3. It is acceptable for the nurses to talk about a client because they are on
the same treatment team.
4. The nurses taking care of the client should not share information that the
 client has told them with each other.

1. Talking about clients in public places is a violation of the client's

confidentiality.

36. Which statement would be considered a judgmental statement?

1. "I don't think you need to do that."
2. "Tell me about making that decision."
3. "I would like to be sure I understood."
4. "When did you first notice you felt that way?"

1. "I don't think you need to do that."

37. A woman with left-sided weakness needs assisted living. The woman's
family plans to sell her home to pay for assisted living, but the woman
refuses to sell because she feels that her family should pay the expenses.
What should the nurse do at this time?
1. Carefully explain the woman's wishes to the family.
2. Ask the woman to share experiences about the house.
3. Arrange a meeting between the children and the woman.
4. Suggest using a power of attorney to deal with the children.

2. Ask the woman to share experiences about the house.

38. The registered nurse is beginning a new job in a clinic and attends an
orientation session. After the session, another new employee asks the
registered nurse to describe case management, a component of the
discussions in the orientation session, because the employee did not clearly
understand the concept. The registered nurse responds by making which
statement?
1. "Case management is an important concept, but it doesn't promote
appropriate use of personnel."
2. "Case management will maximize hospital revenues and at the same time
provide optimal outcome of client care."
3. "Case management saves money for the institution because clients with
similar problems are all treated in the same manner."
4. "Case management requires an experienced nurse because it represents a
primary health prevention focus and is managed by a single nurse."

2. "Case management will maximize hospital revenues and at the same

time provide optimal outcome of client care."

39. The community health nurse is working with disaster relief personnel after
a hurricane that ruined many homes in the local community. The nurse is
working to find housing for the survivors and is organizing counseling
services. Which prevention level does the nurse's actions represent?
1. Primary
 2. Secondary
3. Tertiary
4. Quaternary

3. Tertiary

40. The nurse takes a newly admitted client's vital signs, completes an
admission assessment history on the client, and assists the client to change
into a hospital gown. By completing these tasks, the nurse is demonstrating
which role of the nurse?
1. Manager
2. Educator
3. Advocate
4. Caregiver

4. Caregiver

41. A client refuses to take a medication. Which would be the most therapeutic

response by the nurse?
1. "I'll come back later to see if you have changed your mind."
2. "You don't have to take the medication if you don't want to."
3. "This medication is going to help you get better, why don't you go ahead
and take it?"
4. "Do you want me to call your health care provider (HCP) and tell him
you won't take your medication?"

2. "You don't have to take the medication if you don't want to."

42. The experienced nurse is observing a newly hired graduate nurse count
opioids as part of the orientation process. The experienced nurse determines
that the newly hired nurse needs further teaching about the procedure for
counting opioids when which statement is made?
1. "Any discrepancies in a count will be reported immediately."
2. "I will record each dispensing of an opioid on the special opioids
inventory record."
3. "If a portion of an opioid is used, it is okay to leave it in the client's
drawer to use at another time during the shift."
4. "Opioids will be counted each time one is removed from the drawer and
at the end and beginning of each shift."

3. "If a portion of an opioid is used, it is okay to leave it in the client's

drawer to use at another time during the shift."

43. The nurse is working at a computer in the nurses' station when the charge
nurse from another nursing unit approaches and asks about the condition of
the client in room 432, stating, "The client is my neighbor and I want to
check on her." The nurse should make which most appropriate response?
 1. "I'm sorry, I cannot tell you."
2. "The condition of the client in room 432 is good."
3. "You can get the information from the client's chart."
4. "I don't think you should be asking me that question."

1. "I'm sorry, I cannot tell you."

44. Which client statements best demonstrate to the nurse that the client

understands the concepts of an advance directive? Select all that apply.
1. "This document is a separate document from my final will."
2. "This document is strictly for indicating if I want to be resuscitated."
3. "I need to have my family sign this document in case my condition
worsens."
4. "This document describes the kind of treatment I want depending on how
sick I am."
5. "This document tells what I want and gives medical power of attorney to
my doctor."
o 1. "This document is a separate document from my final will."
o 4. "This document describes the kind of treatment I want
depending on how sick I am."
45. The nurse suspects that a client is not fully aware of the implications of a
procedure and the client is about to sign an informed consent. What action
would be most appropriate for the nurse to take?
1. Ask the client if the doctor explained the procedure before obtaining the
signature.
2. Ask a family member to sign the consent because the client seems unsure
at this time.
3. Tell the client that he can ask the doctor for more details when he gets to
the operating room.
4. Inform the health care provider that the client does not appear to fully
understand the procedure and withhold obtaining the signature.

4. Inform the health care provider that the client does not appear to fully
understand the procedure and withhold obtaining the signature.

46. While making rounds a client asks the nurse, "What's wrong with that lady
in the room next to me? She cries out all night long, and I hope she is
okay." What is the nurse's best response?
1. "She's okay; she just gets confused at night."
2. "I'm not allowed to say anything to you about her."
3. "She has Alzheimer's disease and gets very upset because she is not
home."
4. "I'm sure it's upsetting to hear her cry, but I'm not able to discuss details
about other clients."

4. "I'm sure it's upsetting to hear her cry, but I'm not able to discuss
 details about other clients."

47. A client is scheduled for surgery, and the surgeon has explained the
procedure and is about to obtain informed consent. Which statement by the
client would indicate to the nurse that the client needs more
information before giving informed consent to the procedure?
1. "If I don't have this surgery, then the tumor will grow."
2. "You said you will remove the tumor but will not be removing the entire
breast."
3. "I know my surgeon explained it, but I still don't know why surgery is
needed."
4. "I'll have some pain after the surgery, but it should get better with that
tumor gone."

3. "I know my surgeon explained it, but I still don't know why surgery is
needed."

48. The nurse is caring for a client who is scheduled for electroconvulsive
therapy. The nurse notes that an informed consent has not been obtained for
the procedure. On review of the record, the nurse notes that the admission
was an involuntary hospitalization. Based on this information, the nurse
should make which determination?
1. That an informed consent does not need to be obtained
2. That an informed consent should be obtained from the family
3. That an informed consent needs to be obtained from the client
4. That the health care provider will provide the informed consent

3. That an informed consent needs to be obtained from the client

49. The nurse is caring for a client who has just returned from having a
cystoscopy with biopsy. The nurse should intervene if an unlicensed
assistive personnel (UAP) is observed taking which action?
1. Obtaining the client's vital signs
2. Assisting the client with repositioning in bed
3. Telling the client that warm sitz baths may be prescribed
4. Insisting that the client ambulate immediately after the procedure

4. Insisting that the client ambulate immediately after the procedure

50. A nurse is caring for a client who has just returned from having a right-
sided renal biopsy. The nurse should intervene if an unlicensed assistive
personnel (UAP) is observed taking which action?
1. Obtaining the client's vital signs
2. Positioning the client on the left side
3. Positioning the client on the right side
4. Providing the client with reading materials
 2. Positioning the client on the left side

51. The nurse gives an inaccurate dose of a medication to a client. Following

an assessment of the client, the nurse completes an incident report. The
nurse notifies the nursing supervisor of the medication error and calls the
health care provider to report the occurrence. Which action should the
nurse anticipate?
1. Incident will be reported to the board of nursing.
2. Incident will be documented in the personnel file.
3. The error will result in suspension and be written in the annual
performance appraisal.
4. The incident report will be used to review quality of care and determine
potential risks.

4. The incident report will be used to review quality of care and

determine potential risks.

52. The nurse discovers a coworker in the linen closet injecting a medication
into the antecubital area. Which most appropriate action should the nurse
take?
1. Call the police.
2. Notify security.
3. Call the nursing supervisor.
4. Ignore what was discovered to avoid conflict.

3. Call the nursing supervisor.

53. A hospitalized client tells the nurse that a living will is being prepared and
that the lawyer will be bringing the will to the hospital today for witness
signatures. The client asks the nurse for assistance in obtaining a witness to
the will. Which response by the nurse is most appropriate?
1. "I will need to sign as a witness to your signature."
2. "It is your responsibility to find a witness on your own."
3. "Whoever is available at the time will sign as a witness for you."
4. "I will call the nursing supervisor for assistance regarding your request."

4. "I will call the nursing supervisor for assistance regarding your
request."

54. A nurse has made an error in documenting an assessment finding in the

client's record. What action should the nurse take to correct the error?
1. Write the late entry into the client's record.
2. Erase the error and rewrite the correct data.
3. Use white correction fluid or tape to cover the error and write in the
correct assessment findings.
4. Draw one line through the error, initial and date the line, and then
 provide the correct information.

4. Draw one line through the error, initial and date the line, and then
provide the correct information.

55. A nurse hears a client calling out for help and finds the client lying on the
floor. The nurse performs an assessment and assists the client back to bed.
The health care provider is notified of the incident, and the nurse completes
an incident report. Which detail should the nurse document on the incident
report?
1. The client fell out of bed last night.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client was restless and tried to get up.

3. The client was found lying on the floor.

56. An adult client is brought to the emergency department by emergency

medical services after being hit by a car. The name of the client is not
known. The client has sustained a severe head injury and multiple fractures
and is unconscious. An emergency craniotomy is required. In regard to
informed consent for the surgical procedure, which is the best
initial action?
1. Obtain a court order for the surgical procedure.
2. Transport the victim to the operating room for surgery.
3. Call the police to identify the client and locate the family.
4. Ask the emergency medical services team to sign the informed consent.

2. Transport the victim to the operating room for surgery.

57. The client with a perforated gastric ulcer who is scheduled for emergency
surgery cannot sign the operative consent form because of sedation with
opioid analgesics. The nurse should take which priority action?
1. Have the hospital chaplain sign the informed consent immediately.
2. Send the client to surgery without the consent form being signed.
3. Notify the health care provider to obtain a court order for the surgery.
4. Obtain telephone consent from the family member witnessed by two
clients.

4. Obtain telephone consent from the family member witnessed by two

clients.

58. The unit manager is reviewing documentation describing a client's progress

in terms of a critical path (Care Map) for postoperative colon resection
recovery. The manager notes that, although the documentation is complete,
the client has made minimal progress in the areas of mobility and pain
control for the prior 48 hours. Who should the unit manager contact next?
 1. Assigned nurse to increase client care interventions
2. Family to determine what is wrong and provide suggestions
3. Health care provider and assigned nurse to determine measures to
discharge the client
4. Case manager to determine whether the predicted variance has been
negotiated with the health insurer

4. Case manager to determine whether the predicted variance has been

negotiated with the health insurer

59. A client involved in a head-on automobile crash has awakened from a coma
and asks for her husband, who was killed in the same accident. The family
does not want the client to know at this time that her husband has died. The
family wants all nursing staff to tell the client that the husband was taken
by helicopter to another hospital, has a head injury, and is in the intensive
care unit (ICU). Because the American Nurses Association Code of Ethics
requires the nurse to preserve integrity, but the nurse wants to follow the
family's instruction, the nurse faces an ethical dilemma. Which steps should
the nurse take to systematically process this ethical dilemma?Arrange in
order the steps for systematic processing of the ethical dilemma. All
options must be used.
1. Evaluate the action.
2. Verbalize the problem.
3. Negotiate the outcome.
4. Consider possible courses of action.
5. Gather all of the information relevant to the case.
6. Examine and determine one's own values on the issues.
o 5. Gather all of the information relevant to the case.
o 6. Examine and determine one's own values on the issues.
o 2. Verbalize the problem.
o 4. Consider possible courses of action.
o 3. Negotiate the outcome.
o 1. Evaluate the action.

1.