Managing client care - Saunders PDF

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Which identifies accurate nursing documentation notations? Select all that apply. Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seems or appears, is not acceptable because these words suggest the nurse is stating an opinion.

1.

The client slept through the night.

2.

Abdominal wound dressing is dry and intact without drainage.

5.

The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? Rationale: The incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any reference made to it in the client's record. The incident report is not a substitute for a complete entry in the client's record concerning the incident.

3.

Document a complete entry in the client's record concerning the incident.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? Rationale: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.

4.

Transport the client to the operating department immediately without obtaining an informed consent.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks. When faced with this situation, the nurse should identify potential areas of harm to the client. 4.

Report to the pediatric unit and identify tasks that can be safely performed.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? Rationale: Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility in which the client is receiving care. 1.

Decline to sign the will.

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? Rationale: Proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency. Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present. Options 1, 3, and 4 are incorrect.

2.

A method of promoting quality care and risk management

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? Rationale: Nurse practice acts require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing. Options 1 and 2 are inappropriate. Option 3 may cause a conflict.

4.

Report the information to a nursing supervisor.

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse 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? Rationale: Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment.

3.

Taking photographs of the client without consent

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? Rationale: Confidential issues are not to be discussed with nonmedical personnel or with the client's family or friends without the client's permission. Clients should be assured that information is kept confidential unless it places the nurse under a legal obligation. The nurse must report situations related to child, older adult abuse, and other types of abuse, depending on state laws; gunshot wounds; stabbings; and certain infectious diseases.

1.

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

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

1.

As-needed medications given that shift

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 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 most appropriate assignment for the UAP would be to care for the client who requires frequent ambulation. The UAP is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

2.

A client who requires frequent ambulation

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 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. The assignment of tasks needs to be implemented on the basis of the job description of the individual, the individual's level of clinical competence, and state law. Options 2, 3, and 4 involve care that requires the skill of a licensed nurse. A UAP is not licensed.

1.

A client who requires a 24-hour urine collection

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? Rationale: The airway is always a priority, and the nurse first checks the client on a ventilator. The clients described in options 1, 3, and 4 have needs that would be identified as intermediate priorities.

2.

A client who is dependent on a ventilator

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? Rationale: In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care, the type of illness, the severity of the problem, and the resources available to govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits, and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.

4.

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. Rationale: Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crises. This type of event can occur in the health care facility or outside of it. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe client care.

2.

"Mass casualty events do not require an increase in the number of staff that are needed."

3.

"A mass casualty event occurs only within the heath care facility and could endanger staff."

5.

"A mass casualty event occurs if a fight between visitors occurs in

the emergency department."

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice? Rationale: In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

3.

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

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? Rationale: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff

1.

Autocratic

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 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 implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

4.

Perform follow-up with each staff member regarding the performance and outcome of the task.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? Rationale: The airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 would have intermediate priority.

4.

A client receiving oxygen who is having difficulty breathing

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action? Rationale: During a widespread disaster, many people will be brought to the emergency department for treatment. Health care institutions are required to have an emergency response plan in place and perform practice drills. The initial nursing action should be to activate the emergency response plan. The plan entails the other options, which include preparing triage rooms to take casualties, and obtaining sufficient supplies and medical personnel.

2.

Activate the agency emergency response plan.

A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action? Rationale: External cardiac massage is one type of treatment that a client can refuse. The appropriate initial action is to notify the primary health care provider (PHCP) because a written "do not resuscitate" (DNR) prescription from the PHCP must be present. The DNR prescription must be reviewed or renewed on a regular basis, per agency policy.

3.

Notify the primary health care provider of the client's request.

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply. Rationale: Computer terminals should never be left unattended after the nurse has logged on. This could allow unauthorized users to access the personal information of clients, and it represents a breach of confidentiality and security of client records. Likewise, another user should never be allowed access to one's account. Changing the password for computer entry monthly, shredding the printout of the nurse's flowchart, and using only

personal user names and passwords represent actions that are acceptable ways to protect client information.

1.

Change the password for entering computer files at least monthly.

2.

Shred the printout of the nurse's flowchart at the end of the nurse's shift.

3.

Use own user name and password when logging into the computer system.

Which guidelines should the nurse follow when performing narrative documentation? Select all that apply. Rationale: The nurse always dates and times entries and signs and titles each entry. The nurse provides objective, factual, and complete documentation and avoids subjective, judgmental, and evaluative statements. Quotes are used to relate what the client actually said. The nurse avoids leaving blank spaces on documentation forms because this allows for an area in which notes can be entered by others at a later time. The recording of information in the client's record must be sequential.

1.

Date and time entries.

2.

Sign and title each entry.

3.

Avoid judgmental and evaluative statements.

5.

Do not leave blank spaces on documentation forms.

The home care nurse observes that an older male client is confined to his room by his daughter-in-law. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way, and my son needs me to stay here." Which is the best nursing intervention for this situation? Rationale: Assisting clients and families with becoming aware of available community support systems is a role and responsibility of the nurse. Suggesting to the client and daughterin-law to place the client in a nursing home is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of nursing care required. Observing that the client is confined to his room makes it necessary for the nurse to intervene legally and ethically, so saying nothing in order to remain neutral is not appropriate and is passive in terms of advocacy. Telling the son that confining his father to his room is inhumane is incorrect and judgmental.

4.

Suggest appropriate resources such as respite care and a senior citizens' center to the client and daughter-in-law.

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain

informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action should be implemented? Rationale: Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent and document the name of the family member, noting that an oral consent was obtained. In emergencies, the client may be unable to sign and family members may not be available. In this type of a situation, the primary health care provider is legally permitted to perform surgery without consent so the surgery should not be delayed. Consent is not informed if it is obtained from the...