Professional Documents
Culture Documents
__"You may leave the hospital at any time unless you are suicidal."
__"Let's talk more after the health team has assessed you."
__"Once you've signed the papers, you have no say."
__"Because you could hurt yourself, you must be safe before being
discharged."
__"You need a lawyer to help you make that decision."
__"There must be a court hearing before you leave the hospital."
RATIONALE: With meningitis, the child should be isolated for the first day
but be close to where he can be observed frequently. In isolation off a side hallway is
too far away for frequent observation. Putting the client in a room with another child
who has meningitis or with two toddlers who have croup present an infectious hazard
to the other children.
RATIONALE: When all team members know what needs to be done, they
can work together on the most efficient plan for accomplishing necessary tasks.
Delegation can be flexible, ranging from telling a staff member exactly what needs to
be done and how to do it to allowing team members some freedom to decide how
best to carry out the tasks. Assigning unfinished work to other team members and
assigning each team member the responsibility to obtain dietary trays don't allow for
input from team members. It's the team leader's job to maintain responsibility for the
outcome of a task.
7. The nurse is caring for a client admitted to the emergency
department after a motor vehicle accident. Under the law, the nurse must
obtain informed consent before treatment unless:
RATIONALE: The nurse has spoken to her colleague under the appropriate
circumstances and the behavior hasn't changed. Therefore, the appropriate action is
to bring the problem to the manager's attention. It's unproductive to talk with other
staff members about the situation because they don't have the authority to bring the
colleague's practice into compliance. The nurse should never point out to a client
that another staff member's practice isn't meeting standards.
A. Fraud
B. Defamation of character
C. Assault and battery
D. Breach of confidentiality
RATIONALE: The nurse should refer this client to a sex counselor or other
professional. Making appropriate referrals is a valid part of planning the client's care.
The nurse doesn't normally provide sex counseling.
15. Each state has guidelines that regulate the different levels of
nursing : licensed practical or vocational nurse, registered nurse, or
advanced practice nurse. Legal guidelines outlining the scope of practice
for nurses are known as:
A. consent to treatment.
B. client's bill of rights.
C. nurse practice acts.
D. licensure requirements.
RATIONALE: Each state has a nurse practice act that defines the scope of
nursing practice within the state. Consent to treatment refers to informed consent for
a treatment or procedure. The client's bill of rights defines the rights of clients.
Licensure requirements are constructed by the state board of nursing to set
standards for receiving a nursing license. CBQ ito.
RATIONALE: The nurse is obligated to let him leave. Detaining him in any
form is a violation of the patient's bill of rights.
A. at discharge.
B. during the first meeting.
C. at the midpoint of the relationship.
D. when the client demonstrates the ability to function independently.
22. A client became seriously ill after a nurse gave him the wrong
medication. After his recovery, he files a lawsuit. Who is most likely to be
held liable?
RATIONALE: Nurses are always responsible for their actions. The hospital is
liable for negligent conduct of its employees within the scope of employment.
Consequently, both the nurse and the hospital are liable. Although the mistake wasn't
intentional, standard procedure wasn't followed. CBQ ito.
23. The nurse is providing care for a client who underwent mitral
valve replacement. The best example of a measurable client outcome goal
is to:
RATIONALE: Walking from his room to the end of the hall and back before
discharge is a specific, measurable, attainable, timed goal. It's also a client-oriented
outcome goal. Having the client change his own dressing is incomplete and not as
significant. Just walking in the hall isn't measurable. The need for a special diet isn't
evident in this case.
24. A client with end-stage liver cancer tells the nurse he doesn't
want extraordinary measures used to prolong his life. He asks what he
must do to make these wishes known and legally binding. How should the
nurse respond to the client?
A. Tell him that it's a legal question beyond the scope of nursing
practice.
B. Give him a copy of the client's bill of rights.
C. Provide information on active euthanasia.
D. Discuss documenting his wishes in an advance directive.
26. The nurse is providing care for a client with multiple myeloma,
a disorder characterized by episodes of remissions and exacerbations.
Which resource can best help the client adapt to the disease?
A. Social worker
B. Registered dietitian
C. Occupational therapist
D. Enterostomal nurse therapist
RATIONALE: An enterostomal nurse therapist is a registered nurse who has
received advanced education in an accredited program to care for clients with
stomas. The enterostomal nurse therapist can assist with selection of an appropriate
stoma site, teach about stoma care, and provide emotional support. Social workers
provide counseling and emotional support, but they can't provide preoperative and
postoperative teaching. A registered dietitian can review any dietary changes and
help the client with meal planning. The occupational therapist can assist a client with
regaining independence with activities of daily living.
RATIONALE: When advance directives state that a client doesn't want life-
prolonging interventions, nursing care focuses on providing emotional and spiritual
support and comfort measures. The client still needs to be checked regularly. The
client and family shouldn't feel as if they've been abandoned. Providing mouth and
skin care makes the client more comfortable. Turning the client provides comfort and
prevents potentially painful complications such as pressure ulcers.
A. The nurse should know the hospital's disaster plan and what's
expected of her during a disaster.
B. During a disaster, the nurse should volunteer to help where she
thinks assistance is most needed.
C. The nurse should offer advice about how to keep the operation
running smoothly.
D. If told to do so, the nurse should perform tasks that are beyond her
scope of practice.
RATIONALE: Before a disaster occurs, the nurse should know how the
hospital's disaster plan works and what she'll be required to do in a disaster. During a
disaster, the charge nurse will assign staff to areas where the needs are; therefore, a
nurse may find herself performing tasks outside of her usual practice. This practice is
permitted if the nurse has the knowledge, skill, and comfort level to perform assigned
tasks. However, the nurse should never perform activities outside of the nurse's
scope of practice as outlined in the state's nurse practice act.
A. Autocratic
B. Democratic
C. Participative
D. Laissez-faire
A. Whether the LPN or nurse's aide provided care for the client before
B. The staff member whose turn it is to perform certain, less pleasant
tasks
C. The job description and experience level of the LPN and the aide
D. The staff member who volunteers to perform the various tasks
A. Forming
B. Storming
C. Norming
D. Performing
RATIONALE: If a client requests discharge AMA, the nurse should notify the
physician immediately. If the physician can't convince the client to stay, the physician
will ask the client to sign an AMA form. This form releases the hospital from legal
responsibility. If the physician isn't available, the nurse should obtain the client's
signature on the AMA form. A client who refuses to sign the form shouldn't be
detained; forced detention violates the client's rights. After the client leaves, the
nurse should document the incident thoroughly and notify the physician that the
client has left. CBQ ito.
41. The nurse is caring for a client with renal failure who requires
peritoneal dialysis. The nurse doesn't feel comfortable performing the
procedure. What would be the most appropriate action for the nurse to
take?
A. Omit the procedure and tell the next nurse in report that she'll need
to perform the dialysis.
B. Ask the nursing supervisor for assistance in using the equipment.
C. Ask the client how to use the equipment.
D. Perform the procedure to the best of her ability, utilizing her
knowledge of basic health principles.
A. Cover for the nurse because the profession depends on loyalty from
colleagues.
B. Call the police and ask them to arrest the nurse because she's
endangering the lives of clients.
C. Tell the nurse she has one more chance, but if she drinks on duty
again she'll be reported.
D. Immediately notify the nursing supervisor.
RATIONALE: All entries in the medical record should include the time and
date they were written. The nurse should document observations and measurements,
but avoid giving an interpretation of the data, kc the nurse’s interpretation is
considered subjective and dapat, objective data lang dinodocument. Correcting fluid
is never used to correct an error, hahaha! Kc uso ngaun micropore (jowk). When a
mistake in documentation is made, the nurse should draw a single line through the
entry, write the word error next to it, and sign her name; otherwise, it may appear as
if a nurse is trying to alter or hide information. Never leave blank spaces in the
medical record. The nurse should draw a line through any blank spaces and sign her
name at the end to prevent others from adding information to the entry.
46. The parents of a 4-year-old with sickle cell anemia tell the
nurse that they would like to have other children, but they're concerned
about passing sickle cell anemia on to them. Which health care team
member would be the most appropriate person for the nurse to refer them
to?
A. Clergy
B. Social worker
C. Certified nurse midwife
D. Genetic counselor
47. The family of a child dying from leukemia asks the nurse about
organ donation. Who must give consent for the child's organs to be
donated?
48. Parents whose first child has celiac disease ask the nurse if all
of their children will have the disease. To whom should the nurse refer
them?
A. Registered dietitian
B. Genetic counselor
C. Certified nurse midwife
D. Social worker
49. The nurse is caring for a school-age child with cerebral palsy.
The child has difficulty eating using regular utensils and requires a lot of
assistance. Which of the following referrals is most appropriate?
A. Registered dietitian
B. Physical therapist
C. Occupational therapist
D. Nurse's aide
RATIONALE: The client needs to know that resources are available to her,
and the nurse should help her to find those resources. Health care can be costly, but
it doesn't necessarily mean that the client has no interest in caring for herself or her
child. Taking up a second job doesn't necessarily rectify this situation.
51.The nurse is caring for a client with hyperemesis gravidarum
who will need close monitoring at home. When should the nurse begin
discharge planning?
52. The parents of a 5-year-old call the clinic to tell the nurse that
they think their child has been abused by her day-care provider. What
should the nurse advise them to do?
RATIONALE: The nurse can coordinate care when multiple services are
involved, explaining the function of each service (social services, case management,
counseling services, and so forth). For instance, providing parents with information
about financial assistance programs is the responsibility of social services. Informing
the family of the diagnosis and recently discovered findings is a physician's
responsibility, as are referring and consulting with other specialties. CBQ ito.
A. institutional resources.
B. standards of practice.
C. client-care quality.
D. nursing recruitment.
60. Two family members are arguing in a child's room. They start
to hit each other and the child is crying. What's the most appropriate
nursing action?
RATIONALE: The first action would be to protect the child by removing him
from the room. Calling security is necessary but only after ensuring the safety of the
child. Asking one of the family members to leave the room or reasoning with them
would be ineffective at this point and may even escalate the situation. Wag makialam
sa mga away ng family members ng patient ok.
A. A social worker
B. The medical director of the emergency department
C. A Children's Protective Services (CPS) representative
D. A public health nurse
RATIONALE: Initially, the nurse needs to inform the surgeon that the task is
outside the scope of nursing practice. Bawal ang atribida nad nagmamarunong na
nurse kea, If the surgeon still requests the activity, the nurse should refuse to
perform the task and should follow the chain of communication for reporting unsafe
practice according to the hospital's policy. The nurse must not comply with any order
that goes beyond the scope of nursing practice.
65. Which of the following clients would be a priority for the nurse
to evaluate when assuming responsibility for their care at the beginning of
the day shift?
End of
PROFESSIONAL ADJUSTMENT AND NURSING CARE
MANAGEMENT PRACTICE EXAM