Question 1

During the charge nurse's morning rounds, a client says, "I hope you will take better care of me than the nurse I had last night." What should be the charge nurse's initial response?

Accepted Answer

The first step in management issues, just as in nursing care, is assessment. The charge nurse must first determine what happened before deciding the next course of action. The client could have misperceived certain actions (Option B). (Option A) It is important to determine what happened before apologizing for any staff behavior. The charge nurse could issue a "blameless apology" ("I'm sorry you are upset" or "I'm sorry you think you did not receive what you needed last night"). However, the option indicates an apology for the nurse's treatment, which may have been appropriate. The charge nurse needs a description of what occurred in order to take action against misperceptions or inappropriate staff behavior. (Option C) This statement might be true but does not rectify the situation. The client's concern may be related to something, such as tone of voice, not directly related to client load. (Option D) Until the charge nurse understands the client's issue with care the previous night, the nurse cannot realistically say that things will be different or better today. That is false reassurance. Educational objective: When a client complains about staff treatment, the first response should be to assess the client's perceived wrong. The nurse can then determine what follow-up action is needed.

Question 2

A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse?

Accepted Answer

When there is inter-staff disagreement, it is important to not have a public "show." The first action should be to take the conflict "off stage." This is especially true when there is a power/authority difference (eg, HCP/nurse). Rather than suggest and wait, the nurse should immediately leave and go to a private area. That way the disruptive person has to either follow the nurse or stop talking because there is no longer an audience. Once in private, the nurse can acknowledge the HCP's concerns and work to resolve the issue (Option D). (Option A) Confrontation and aggressive response usually do not resolve or diffuse the situation and will still involve an audience. (Option B) The nurse should first take the conversation private as the HCP is not likely to calm down soon. The nurse can offer a blameless apology (eg, "I'm sorry there has been a problem") and then focus on the solution. This should occur out of the public eye. (Option C) This response involves avoidance rather than working to resolve the situation. It does not benefit staff or clients to see providers having a public disagreement. Educational objective: The first response to public displays of disruptive behavior is to take action to make the conversation private.

Question 3

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response?

Accepted Answer

When clients are hospitalized, they lose control of many things, including their medication management. This loss of control can be frightening for the client, especially one who has had control of medications for many years. This client, who has a decade of experience taking methadone for chronic pain, is afraid that suddenly stopping this medication may precipitate withdrawal. The client is trying to regain control and avoid this problem by leaving the hospital against medical advice. However, the client remains at risk of life-threatening arrhythmias. Therefore, the nurse should promote negotiation between the client and HCP to develop a plan of care that will address the concerns of each. The plan should advocate for the client to ensure that the concerns are addressed. Care planning should be a collaborative, shared process informed by the knowledge and preferences of the client and evidence-based recommendations by the HCP that are appropriate to the situation. (Option B) This response is based on the idea of the nurse and HCP being in control, but it fails to include the client in the decision-making team. (Option C) This statement provides a rationale for the client to remain in the hospital, but it does not address the client's concerns about going into withdrawal. (Option D) This response is based on the idea of client autonomy, but it does not propose a solution to the problem. Educational objective: A plan of care should be developed collaboratively, informed by the client's knowledge, beliefs, and preferences, and the expertise and evidence-based recommendations of HCPs.

Question 4

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse?

Accepted Answer

The nurse should be assertive and deal with the issue directly now. The nurse is using an "I" statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand, which the UAP can perform. The request should be given as a directive, not as an option. Putting the request in the scope of a universal goal on which everyone can agree, such as quality care, makes it harder for the UAP to refuse. It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts the requested action. (Option A) The request should not be given as an option as there is a legitimate need the UAP can meet. The nurse needs to be directive and assertive when indicating what needs to be done. (Option C) This is an avoidance action and does not resolve the bigger issue. The nurse should attempt to rectify the issue first rather than focus on discipline. Discipline measures are appropriate if there is insubordination (the UAP refuses) or a pattern of behavior (on every shift the UAP does not answer lights despite being told). (Option D) The nurse should give the UAP a chance to change behavior first. Speaking to the manager in the future does not resolve the current issue. The nurse can take this step if there is insubordination or a pattern of behavior. Educational objective: The nurse should use assertive communication techniques to deal with a staff member directly and immediately by telling rather than asking for certain actions. The nurse should not attack the individual's character or initially make threats (aggression) and should not avoid the issue by just performing the action itself (avoidance).

Question 5

The health care provider (HCP) remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially?

Accepted Answer

Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is prohibited. Other behaviors that could be defined as sexual harassment include asking someone for a date after the other person expressed disinterest or making remarks about a person's gender or body. The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP should stop. The offending HCP may have erroneously perceived a mutual attraction. If that is not effective, additional action should be taken. The American Nurses Association cites 4 tactics to fight workplace sexual harassment: confront, report, document, and support. (Option A) The incident should be reported, especially if the offending HCP does not stop. If the harasser is the immediate supervisor, the receiving nurse should go up the chain of command. However, the nurse should first simply tell the offending HCP to stop and see if that resolves the issue. (Option C) The nurse should respond with assertiveness, not avoidance. Ignoring the situation may imply that the nurse does not mind the HCP's attention. (Option D) The receiving nurse should document what occurred and how the nurse responded. The presence of witnesses should be documented. Documentation should be stored somewhere other than the workplace. However, the nurse should initially communicate assertively that the actions are to stop before documenting them. Educational objective: A nurse who receives unwanted sexual advances in the workplace should first immediately and clearly indicate that the advances are unwanted and that the offending person should stop.

Question 6

After talking to the client, the health care provider (HCP) tells the registered nurse that the client's signature is needed on the consent form that has been filled out.  While the nurse is obtaining the signature, the client states, "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy."  What action should the nurse take?

Accepted Answer

The HCP performing the surgery should explain the risks, benefits, and alternatives of the specific procedure to the client. However, the nurse can witness the client's signing of the consent form; this differs from "obtaining consent." If the client had a question about the procedure, or the risks, alternatives, or outcomes, then the HCP should be contacted to provide additional teaching to the client. However, an ordinary question about general care or health care teaching can be answered by the nurse as this is part of the nurse's role. (Options A, B, and D) As the client is not asking about details related to the procedure, it is unnecessary for the HCP to return to talk to the client (unless the client specifically asks for this). The client's question does not interfere with the ability to legitimately sign consent for the procedure or with the nurse's witnessing of the client signing the consent form. Educational objective: It is the HCP's responsibility to obtain informed consent and explain the procedure's risks, benefits, and alternatives to the client. The nurse can witness the client's signature and provide normal teaching. If the client has a question about the proposed procedure/surgery, the HCP should return and provide additional teaching.

Question 7

The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation of a client. The RN observes the UAP placing the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. What action should the RN take initially?

Accepted Answer

The Foley bag is too high and needs to be lowered. When observing a provider making an error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client. (Option A) Future inservice education is not a timely solution to this immediate need. It is appropriate to carry out teaching first rather than initiate disciplinary actions. According to the Federal Drug Administration's (FDA's) mandate, as no serious harm was caused, the incident does not need to be reported. (Option B) The most important issue needing intervention is the improper positioning (too high) of the Foley catheter bag. Positive reinforcement for appropriate actions can also be included (and is beneficial), but the error should first be corrected to prevent harm. (Option D) It is important to attend to the error right away to help ensure that the UAP does not repeat it. Letting this UAP complete assigned tasks first does not immediately deal with the incorrect position of the Foley bag and may not effectively teach (aid retention of) the correct positioning to the UAP. Educational objective: When observing a provider making an error, correct it immediately to stop any potential harm to the client. Correct the provider privately and as soon as possible.

Question 8

A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the bestaction by the nurse?

Accepted Answer

The medicine healer, or shaman, is an important component of Native American culture and is often consulted by both clients and HCPs when a client is ill or hospitalized. The medicine healer uses a variety of practices, including herbs, plants and roots, singing, and healing ceremonies. The medicine healer needs to be included in this client's treatment. Making arrangements for the healing ritual gives credibility and respect to the client's cultural beliefs and ensures that the client's spiritual needs will be met. In providing culturally sensitive care, the nurse needs to recognize and be tolerant of various practices associated with beliefs that are different from those of traditional Western medicine. Denying the medicine healer the opportunity to perform a ritual could interfere with the client's response to therapy. (Option A) Although it may be true that the client's depression is being treated with antidepressants, the medications do not meet the client's spiritual needs. (Option B) This response demeans the client's beliefs and does not acknowledge the importance of the medicine healer to the client's health. (Option D) Allowances and accommodations should be made by health care facilities to ensure that clients' spiritual needs are met. Educational objective: Medicine healers, or shamans, are an important component of Native American and other cultural groups. Allowing medicine healers to perform rituals and ceremonies will ensure that clients' spiritual needs are met and may contribute to the healing process. The nurse needs to recognize and be tolerant of health practices and beliefs that are different from those of traditional Western medicine.

Question 9

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply.

Accepted Answer

A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change, department transfer). Transitions of care require thorough, precise communication to ensure client wellness and safety. Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's care. To ensure appropriate and effective handoff communication, the nurse should: Provide identifying information (eg, client's name and room number). Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform delayed wound care and cause of delay) (Option A). Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option C). Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) (Option E). Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation). (Option B) Report statements should include exact information (ie, time medication is administered, measurable outcome using a pain scale). "Good relief" is a vague term. (Option D) Handoff should not include biased information or personal opinions (eg, "rude") and should include visitor information only if the visitor is involved in client care and/or teaching. It is appropriate to include information about a client's medication list. Educational objective: Nurse-to-nurse handoff of care reports should clearly communicate identifying information; care priorities and upcoming or outstanding tasks; exact, pertinent information; multidisciplinary plans; and significant client changes.

Question 10

Which situations require that the registered nurse (RN) report to an appropriate authority? Select all that apply.

Accepted Answer

The RN is required to report suspected abuse of vulnerable clients (eg, underage, elderly, mentally ill) to appropriate authorities, regardless of what other practitioners think. A proper investigation, rather than conflicting opinions, will determine whether abuse has occurred (Option C). The RN should report suspected abuse of vulnerable clients even if the client denies it because other factors (eg, dependence on the abuser, dementia) could be the reason for denial (Option D). Sexually transmitted infection (STI) in a child is sexual abuse and must be reported and investigated (Option E). The greater good of society outweighs an individual's right to confidentiality. Gonorrhea is an STI; the client should be informed that public health will be notified and partners will be contacted to receive treatment (Option B). (Option A) Cupping is a recognized alternative medicine practice in which a circular object is typically used to create suction underneath a cup. The tension pulls the skin upward and promotes release of muscle tension and scar tissue. After the process, the circular marks remain for a certain period. The location, organized rows, and history help validate the cause of the marks. Educational objective: An RN is required to report suspected abuse of vulnerable clients even if other practitioners do not agree or the clients deny it. An STI in a child is considered sexual abuse and requires reporting. Reportable conditions by law are not protected from reporting under the confidentiality of personal health care information in HIPAA.

Question 11

A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply.

Accepted Answer

Several adjunctive professional services assist clients in the post-acute phase of their illness as part of an overall interdisciplinary team. Speech therapy focuses on speech and communication but also on swallowing/eating issues (Option D). A client with a stroke will need to be evaluated for any aspiration risks and taught how to minimize those risks (eg, chin-down positioning, chewing on the non-affected side of the mouth). Social workers assist with developing coping skills, securing adequate financial resources or housing, and making referrals to volunteer organizations (Option C). Wound care is a resource for assessing and planning the optimal care of any wound (Option E). (Option A) Occupational therapy emphasizes the skills necessary for activities of daily living (eg, dressing, bathing, cognitive or perception issues); however, walker training is performed by a physical therapist. An overly broad generalization is that occupational therapy is for "above the waist." (Option B) Physical therapy focuses on mobility, ambulation, ability to transfer, and use of related equipment. An overly broad generalization is that physical therapy is for "below the waist." Dressing skills would be taught via occupational therapy. Educational objective: Some of the adjunctive professional services in post-acute care include wound care (eg, assessing/planning wound treatment), speech therapy (eg, communicating, swallowing, eating), social work (eg, coping, connecting to resources), physical therapy (eg, mobility, ambulating, using equipment), and occupational therapy (eg, activities of daily living).

Question 12

The nurse is providing handoff-of-care report to the oncoming nurse for a client admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during handoff report?

Accepted Answer

Current respiratory status is essential to include in handoff report, as it is objective information related to the client's current condition. Information communicated during report should allow the oncoming nurse to prioritize care and obtain baseline measurements of the client's current status and response to treatment. It is especially important to include information that may not be documented in the medical record. Respiratory status can change rapidly, and the most current measurements may not be documented, as vital signs are often documented every 4, 8, or 12 hours (Option C). Handoff report typically includes: Client's name, location, age, gender, health care provider, and diagnoses Client's current baseline measurements, treatment plan, goals, and response to treatment Priority and outstanding tasks and changes from previous days (Option A) Lung infiltrates and elevated WBC count are expected findings with pneumonia and are found in the medical record. Diagnostic findings are significant if there is an ongoing trend, but isolated, expected results are not as helpful in planning care. (Option B) Personal opinions are not pertinent to providing care. (Option D) The client's IV site is assumed to be patent without complication, or the offgoing nurse would have changed it. The oncoming nurse should make an individual assessment. Educational objective: Handoff report should include objective information related to the client's current condition. It is especially important to include baseline measurements that may not be documented in the medical record (eg, current respiratory status) so that the oncoming nurse can prioritize care.

Question 13

A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which is the most appropriate action by the nurse?

Accepted Answer

The nursing role in advocating for the client includes ensuring the use of interpreters for clients who speak a different language, particularly during the informed consent process. The person interpreting for the client should ideally possess the following: Training in medical terminology and procedures Ability to protect the client's rights in a medical setting Fluency in the language Understanding of cultural beliefs and nuances For these reasons, and to protect client confidentiality, family members should not be used as medical interpreters unless the situation is urgent and a family member is the only one available to fill this role. (Option A) The nurse may act as a witness, but this is less important than ensuring appropriate resources are used to carry out the informed consent process. (Option B) The nurse is responsible to provide preoperative teaching, but this is less important in this situation than ensuring that an appropriate informed consent process is followed. (Option C) The use of family members as translators of medical information is not ideal but may be used when necessary, particularly when a situation is urgent and an interpreter is not available. Educational objective: The nurse acting as a client advocate should ensure the appropriate use of medical interpreters to promote adequate client understanding and participation in the decision-making process. This is particularly important during the informed consent process.

Question 14

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in the child's home, but the nurse is questioning the safety of the home. The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed. It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment?

Accepted Answer

An important part of the nursing role is to advocate for the health and safety of the client. This client has fallen and lost weight when living in the child's home, prompting the nurse to advocate for the client by bringing in other members of the interdisciplinary team to assess the home situation. When a nurse is concerned about the client's living situation, the social worker is the most appropriate team member to consult with first. The role of the social worker includes assessing the client's living situation and arranging for an alternate living situation or support services as needed. (Option A) Adult protective services would be notified when abuse or neglect is suspected. In the hospital setting, a social worker should be contacted to do a detailed assessment of the situation before adult protective services is notified. (Option B) The physical therapist should be consulted when there is concern about the client's ability to function safely in the home environment. (Option C) The physician would not be the most appropriate person to appoint when a detailed assessment of the home living situation needs to be conducted. However, the physician should be notified if a social worker is assigned to assess the home living situation. Educational objective: Nursing advocacy for the safety of the client includes the appropriate use of interdisciplinary team members, such as the social worker. Advocacy is especially important in younger and elderly clients and those who are cognitively challenged or have mental health concerns.

Question 15

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services?

Accepted Answer

Individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services. Clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and anxiety. Mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster. Services may be provided in shelters, food distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes. However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because: Clients may not know where or how to seek help Clients may be afraid or unable to leave their homes Telephone services and other lines of communication may be disrupted Potential clients may leave their homes and go to shelters or alternate housing Transportation may be severely limited It is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services. The mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments. (Option A) Contacting other social service agencies may be part of an effort to coordinate services once the team has reported in to the local command center. (Option B) This is an appropriate outreach strategy after the mobile crisis team has checked in at the local command center and has received the assignments. (Option C) Putting up flyers may not be a particularly effective way to provide outreach to those affected by a disaster as clients may be afraid to leave their homes or they may be unable to get to where the services are being provided. Educational objective: Individuals impacted by natural disasters or emergencies are often in need of mental health services for assistance in coping with a wide range of reactions and emotions including fear, confusion, hopelessness, and anxiety. Outreach strategies in the aftermath of a disaster need to be centrally coordinated by the various community agencies providing services in order to maximize efficiency and avoid duplicative efforts.

Question 16

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply.

Accepted Answer

PID is an acute infection of the upper genital tract. The most common organisms are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same room. There is no infection risk for a client with gastrointestinal bleeding (Option D). Clients with the same organism can room together (Option E). (Option A) Varicella (chicken pox, herpes zoster) requires airborne precautions (and contact precautions also if open lesions are present). Pertussis requires droplet precautions. Both the precautions and the organisms are different, and the clients could cross-infect each other. (Option B) An AIIR (formerly negative-airflow room) is indicated when the client has an organism transmitted by the airborne route (eg, tuberculosis). No other client should be in the room with a client with this type of infection, especially one with a significant co-morbidity. (Option C) Chemotherapy causes bone marrow suppression with immunosuppression. Although the client may not need reverse or protective isolation (eg, when absolute neutrophil count is ≤500/mm³), an infectious client should not be placed with this client. Yellow sputum typically indicates bacterial infection. COPD clients can have chronic colored sputum, but infection (bacterial or viral) is the primary cause of exacerbations (the most likely reason the client is in the hospital). This is not a safe option. Educational objective: For infection control, clients with same organisms can be placed together. Infectious clients cannot be placed with immunosuppressed or at-risk clients.

Question 17

An admitted emergency department (ED) client is waiting for an intensive care unit (ICU) bed to be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first?

Accepted Answer

It is important to move the client to the ICU and for the ED to continue to care for incoming clients. The nursing supervisor, who serves as an "officer" of the facility, can help resolve interdepartmental issues when it is necessary for a higher authority to intervene and expedite processes (Option B). (Option A) The telemetry unit manager would not have the authority to transfer a client. Although the manager could suggest other transfers, prescriptions for the transfers would still be necessary. The nursing supervisor can work with the telemetry manager as needed. (Option C) The client needs appropriate monitoring equipment and staff, not just a physical bed. A high-acuity client is not held in a hallway without adequate caregiving support. (Option D) The client will be held until a bed and staff are available in the appropriate unit. However, the charge nurse should at least try to facilitate a timely transfer. Educational objective: A higher level of authority/chain of command, such as the nursing supervisor, should handle interdepartmental difficulties.

Question 18

The nurse calls the health care provider at midnight and states, "Client X in room 212 had a colectomy yesterday and is now lethargic. The client currently has a rising pulse at 130/min and a falling systolic blood pressure at 80 mm Hg. I am concerned that the client is going into shock." With regard to the SBAR (Situation, Background, Assessment, and Recommendation/Request) communication technique, what is the most important information excluded by the nurse?

Accepted Answer

11ecbb05_cbad_5e8a_b433_b7ea08de2a4a_MD0009_00 SBAR has been updated in some facilities to I-SBAR-R (Introduction, Situation, Background, Assessment, Recommendation/Request, and Read-back). This communication technique is a framework to provide essential information in an organized fashion. It is recommended by the Joint Commission and is especially useful when a client's condition is changing rapidly. In this case, the nurse has omitted the Recommendation/Request of SBAR when communicating with the health care provider (HCP). Examples of appropriate recommendations include asking the HCP to see the client, perform a diagnostic test, request a consultation, or prescribe IV fluid administration. (Option A) The "B" in SBAR stands for background or recent history (eg, the surgery in this case). It is unnecessary to give basic demographic information (eg, age, religion) unless the information is pertinent to the current situation. (Option B) Although temperature and trend could be communicated, the vital signs that the nurse has reported are concerning enough for the HCP to act. A fever/infection is unlikely in the first 24 hours after surgery. (Option D) The "S" is standard for situation (ie, the current change in the client). The focus of the conversation is the current change in response to a recent procedure, not the client's past medical history. Educational objective: SBAR (or I-SBAR-R [Introduction, Situation, Background, Assessment, Recommendation/Request, and Read-back]) is used to communicate pertinent information regarding changes in a client's condition in an organized fashion. The content should include the situation (why the nurse is calling), background, assessment, and a recommendation/request of the health care provider.

Question 19

Which components are used in determining the standards of professional nursing practice? Select all that apply.

Accepted Answer

Standards of nursing practice and care are universal criteria that are used when determining if appropriate, professional care has been delivered. The definition of this minimum acceptable level of care reflects what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations (Options B, C, and D). (Option A) The standard of care includes objective criteria and does not consider intention. Guidelines are used in determining if duties were performed in an appropriate manner. A nurse can have good intentions but still fail to meet the standards of professional nursing practice. (Option E) Standard of care is determined by objective, third-party authoritative/reasonably reliable sources. Nurses who are suspected of negligence, yet cannot provide documentation of the event in question, can testify about their interpretation of usual custom and practice as it relates to the incident. However, an individual's typical actions are not authoritative in determining the universal standard of nursing care and cannot replace the use of objective, authoritative, and predetermined standards of care. Educational objective: The standards of professional nursing practice and care are defined by what reasonable, prudent nurses would do in specific circumstances. These are based on objective, third-party authoritative sources, including literature, laws (Nurse Practice Act), and professional organizations.

Question 20

A nurse is admitting a child who has leukemia.  Several rooms are available on the pediatric unit.  Which client could share a room with this child?

Accepted Answer

Leukemia is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity. This disorder is the most common form of childhood cancer. Infection is a major concern due to neutropenia. In addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a result of decreased platelet production. It would be appropriate for this client with leukemia to share a room with a client with minimal change nephrotic syndrome (MCNS). MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia. (Option A) Appendicitis is a result of viral or infectious processes and can lead to rupture of the appendix. A client recovering from a ruptured appendix poses a threat of infection to the child who has leukemia. (Option B) A client with cystic fibrosis has pulmonary complications due to thick mucus that traps bacteria. The tracheobronchial tree is colonized with bacteria and respiratory infections are a lifelong problem. This client poses a threat of infection to the child with leukemia. (Option D) Rheumatic fever occurs following pharyngitis caused by group A β-hemolytic Streptococcus. A client with this condition poses a threat of infection to the child with leukemia. Educational objective: Leukemia is a cancer of the blood and organs involved in hematologic function. Due to myelosuppression, clients are at risk for problems related to infection, anemia, and bleeding.

Exam 5: Leadership & Management

During the charge nurse's morning rounds, a client says, "I hope you will take better care of me than the nurse I had last night." What should be the charge nurse's initial response?

A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse?

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse?

The health care provider (HCP) remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially?

A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the bestaction by the nurse?

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply.

Which situations require that the registered nurse (RN) report to an appropriate authority? Select all that apply.

A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply.

The nurse is providing handoff-of-care report to the oncoming nurse for a client admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during handoff report?

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services?

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply.

Which components are used in determining the standards of professional nursing practice? Select all that apply.

A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child?