RATIONALE: Critical pathways are management tools developed for particular types of cases or conditions.

They set forth expectations for interventions, outcomes , and client progression. Elements of the nursing care plan are commonly folded

into the critical pathway. The descriptions of standardized and multidisciplinar y plans of care don't adequately describe the critical pathway. Because the crit ical pathway is standardized andmultidisciplinary, the nurse may need to develop a separate care plan to document nursing diagnoses for an individual client.<br >NURSINGPROCESS STEP: Planning<br>CLIENT NEEDS CATEGORY: Safe, effective care en vironment<br>CLIENT NEEDS SUBCATEGORY:Management of care<br>COGNITIVE LEVEL: Kno wledgeA train accident sends a large number of injured passengers to the hospita l. The hospital's disaster plan is put into effect. Which one of the followingnu rsing actions will best serve the hospital in a disaster situation?The nurse sho uld now the hospital's disaster plan and what's expected of her during a disast er.During a disaster, the nurse should volunteer to help where she thin s assist ance is most needed.The nurse should offer advice about how to eep the operatio n running smoothly.If told to do so, the nurse should perform tas s that are bey ond her scope of practice.RATIONALE: Before a disaster occurs, the nurse should now how the hospital's disaster plan wor s 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 tas s outside of her usual practice. This practice is permitted if the nurse has the nowledge, s ill, and comfort level to perform assigned tas s. However, the nurse shouldneve r perform activities outside of the nurse's scope of practice as outlined in the state's nurse practice act.<br>NURSING PROCESS STEP:Planning<br>CLIENT NEEDS CA TEGORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: ApplicationThe nurse-manager of a hospital unit hol ds monthly staff meetings. During these meetings, she maintains control over the meeting and agenda, resistsconsensus decision ma ing, and uses discipline and c oercion to elicit desired behavior from staff. This manager uses what type of le adership style?AutocraticDemocraticParticipativeLaissez-faireRATIONALE: Autocrat ic leaders obtain power with a group by maintaining control over the group. Demo cratic leaders share power by allowingconsensus decision ma ing and distribution of power. Participative leadership is another term for democratic leadership. L aissez-faire leaders maintainno control over the group; decision ma ing is unstr uctured and commonly performed by an unofficial leader of the group.<br>NURSING PROCESSSTEP: Evaluation<br>CLIENT NEEDS CATEGORY: Safe, effective care environme nt<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: AnalysisT he registered nurse of a hospital unit is acting as charge nurse. The charge nur se's responsibility is to delegate client care appropriately to the licensed pra ctical nurse (LPN) and the nurse's aide. Delegation of activities should be prim arily based on which factors?Whether the LPN or nurse's aide provided care for t he client beforeThe staff member whose turn it is to perform certain, less pleas ant tas sThe job description and experience level of the LPN and the aideThe sta ff member who volunteers to perform the various tas sRATIONALE: The primary cons iderations related to appropriate and effective care delegation are the job desc riptions of the assistive staff membersand their levels of expertise. Both facto rs must be considered together, neither in isolation. The other options identify factors that may help determineclient care assignments, but only after consider ing job description and experience levels.<br>NURSING PROCESS STEP:Implementatio n<br>CLIENT NEEDS CATEGORY: Safe, effective care environment<br>CLIENT NEEDS SUB CATEGORY: Management of care<br>COGNITIVE LEVEL: ApplicationA tas force is form ed to analyze institutional problems, such as inadequate staffing and a rise in the number of negative evaluations from clients.During the meeting, members expr ess their concerns, disagree over the most significant factors contributing to t hese problems, and compete for influence over the group. Which of the following four stages of group development does their behavior represent?FormingStorming N ormingPerformingRATIONALE: Storming refers to the stage when resistance to group influence occurs and the objectives of the group aren't yet clearly established .Forming is the first stage, when the members of the group first meet. During th e norming stage, which occurs after storming, consensus begins toevolve, cohesio n and norms develop, and conflict and resistance are resolved. Performing is the stage when the group focuses on the tas at hand andconstructive group efforts improve tas performance.<br>NURSING PROCESS STEP: Assessment<br>CLIENT NEEDS CA

TEGORY: Safe,effective care environment<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: AnalysisA client in the final stages of terminal can cer tells his nurse, "I wish I could just be allowed to die. I'm tired of fighti ng this illness. I've lived a goodlife. I continue my chemotherapy and radiation treatments only because my family wants me to." What's the nurse's best respons e?"Would you li e to tal to a psychologist about your thoughts and feelings?""W ould you li e to tal to your minister about the significance of death?""Would y ou li e to meet with your family and your physician about this matter?""I now y ou are tired of fighting this illness, but death will come in due time."RATIONAL E: The nurse has a moral and professional responsibility to advocate for clients who experience decreased independence, loss of freedomof action, and interferen ce with their ability to ma e autonomous choices. Coordinating a meeting between the physician and family members mayallow the client an opportunity to express his wishes and promote awareness of his feelings, as well as influence future ca re decisions. All other optionsare inappropriate.<br>NURSING PROCESS STEP: Imple mentation<br>CLIENT NEEDS CATEGORY: Safe, effective careenvironment<br>CLIENT NE EDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: AnalysisThe nurse wor s in a managed-care environment. The nurse is expected to be oriented to which of the following criteria?Performing tas s in the shortest time possibleAdhering to client preferencesProblem solving and time managementQuality of care and cost-c ontainmentRATIONALE: Managed care principles mandate the most efficient use of l imited resources; therefore, quality of care and cost-containment are themain is sues. Nurses must loo for the most cost-effective method of achieving a desired outcome without compromising quality. Problem solving andtime management are s ills used to implement the care plan, but aren't unique to the managed care envi ronment. Performing tas s quic ly doesn'talways achieve quality care. Adhering t o client preferences isn't a guiding principle.<br>NURSING PROCESS STEP: Plannin g<br>CLIENT NEEDSCATEGORY: Safe, effective care environment<br>CLIENT NEEDS SUBC ATEGORY: Management of care<br>COGNITIVE LEVEL: KnowledgeA client as s to be dis charged from the health care facility against medical advice (AMA). What should the nurse do?Ta e measures to prevent the client from leaving.As the client to sign an AMA form.Call a security guard to help detain the client. Notify the phy sician.

RATIONALE: If a client requests discharge AMA, the nurse should notify the physi cian immediately. If the physician can't convince the client to stay,the physici an will as the client to sign an AMA form. This form releases the hospital from legal responsibility. If the physician isn't available, thenurse should obtain the client's signature on the AMA form. A client who refuses to sign the form sh ouldn't be detained; forced detention violates theclient's rights. After the cli ent leaves, the nurse should document the incident thoroughly and notify the phy sician that the client hasleft.<br>NURSING PROCESS STEP: Implementation<br>CLIEN T NEEDS CATEGORY: Safe, effective care environment<br>CLIENT NEEDSSUBCATEGORY: M anagement of care<br>COGNITIVE LEVEL: KnowledgeThe nurse is caring for a client with renal failure who requires peritoneal dialysis. The nurse doesn't feel comf ortable performing the procedure. Whatwould be the most appropriate action for t

he nurse to ta e?Omit the procedure and tell the next nurse in report that she'l l need to perform the dialysis.As the nursing supervisor for assistance in usin g the equipment.As the client how to use the equipment.Perform the procedure to the best of her ability, utilizing her nowledge of basic health principles.RAT IONALE: When a nurse is unsure about a procedure or piece of equipment, she shou ld tell the nursing supervisor that she isn't comfortable andas for assistance with the tas . If appropriate training or assistance isn't available, the nurse should as for a different assignment. The procedureshouldn't be omitted for the shift because this could lead to serious complications for the client. The nurs e should never perform a procedure that shedoesn't feel prepared to perform.<br> NURSING PROCESS STEP: Planning<br>CLIENT NEEDS CATEGORY: Safe, effective careenv ironment<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: Ana lysisA registered nurse suspects that another nurse has been drin ing. She smell s alcohol on the nurse's breath and notes slurred speech. What's the bestcourse of action for the registered nurse to ta e?Cover for the nurse because the profe ssion depends on loyalty from colleagues.Call the police and as them to arrest the nurse because she's endangering the lives of clients.Tell the nurse she has one more chance, but if she drin s on duty again she'll be reported.Immediately notify the nursing supervisor.RATIONALE: A nurse who suspects another nurse of i mpaired practice has a duty to report the colleague to the nursing supervisor, n ot the police. Anurse who fails to report an impaired nurse may face disciplinar y action. The nurse shouldn't cover for an impaired nurse or give her one more c hance.These actions place clients at ris , place the nurse at ris for disciplin ary action, and prevent the impaired nurse from receiving help.<br>NURSINGPROCES S STEP: Implementation<br>CLIENT NEEDS CATEGORY: Safe, effective care environmen t<br>CLIENT NEEDS SUBCATEGORY:Management of care<br>COGNITIVE LEVEL: AnalysisWhe n documenting care in a client's medical record, the nurse should:record the nur se's interpretation of data.correct a mista e using a correcting fluid.record th e time and date for all entries.leave blan spaces to record information at a la ter time, if necessary.RATIONALE: All entries in the medical record should inclu de the time and date they were written. The nurse should document observations a ndmeasurements, but avoid giving an interpretation of the data. Correcting fluid is never used to correct an error. When a mista e in documentation ismade, 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 istrying to alter or hide information. Never leave blan spaces in the medical record. The nurse s hould draw a line through any blan spaces and sign her name at the end to preve nt others from adding information to the entry.<br>NURSING PROCESS STEP: Impleme ntation<br>CLIENT NEEDSCATEGORY: Safe, effective care environment<br>CLIENT NEED S SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: ApplicationThe nurse is co mpleting a change-of-shift report. Which statement wouldn't be appropriate for a nurse to include in the report?The client was admitted with a diagnosis of myoc ardial infarction.The client lives at home with his wife and two children.The cl ient had chest pain relieved with one sublingual nitroglycerin tablet.The client is scheduled for a cardiac catheterization in the morning and will be nothing b y mouth after midnight.RATIONALE: Biographical data provided in the client's Kar dex or care plan shouldn't be repeated in a change-of-shift report. The shift re port shouldinclude essential information, such as the client's name, sex, age, c hanges in the client's condition, treatments, and the client's response to treat ment.Other significant information, such as scheduled tests and preparations, ma y be included.<br>NURSING PROCESS STEP:Implementation<br>CLIENT NEEDS CATEGORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY: Management of care <br>COGNITIVE LEVEL: KnowledgeA 19-year-old male client is diagnosed with prosta te cancer. Which nursing action constitutes an invasion of the client's privacy? Covering the client with a blan et before transporting him through the hospital corridorsPulling a curtain around the bed before performing a prostate examinati onRefusing to discuss the details of the young man's condition with cowor ers in an elevator filled with staff Telling the family that the client has cancer wit hout the client's nowledgeRATIONALE: Providing information to an adult client's family without the client's nowledge or permission is an invasion of the clien

t's privacy. Theother options <font face="LWWSYM">-</font> properly covering a c lient before moving him through hospital corridors, shielding a client during pe rsonal care, refusing to discuss client information with people who don't have a need to now <font face="LWWSYM">-</font> all demonstrateappropriate respect fo r the client's privacy.<br>NURSING PROCESS STEP: Implementation<br>CLIENT NEEDS CATEGORY: Safe, effective careenvironment<br>CLIENT NEEDS SUBCATEGORY: Managemen t of care<br>COGNITIVE LEVEL: KnowledgeThe parents of a 4-year-old with sic le c ell anemia tell the nurse that they would li e to have other children, but they' re concerned about passing sic lecell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to?Clerg ySocial wor er Certified nurse midwifeGenetic counselor RATIONALE: A genetic cou nselor can educate the couple about an inherited disorder, screening tests that can be done, and treatments and can provideemotional support. Clergy are availab le to provide spiritual support. A social wor er can provide emotional support a nd help with referrals for financial problems. A nurse midwife cares for women d uring pregnancy and birth.<br>NURSING PROCESS STEP: Planning<br>CLIENT NEEDSCATE GORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY: Management o f care<br>COGNITIVE LEVEL:ComprehensionThe family of a child dying from leu emia as s the nurse about organ donation. Who must give consent for the child's orga ns to be donated?Member of the clergyPhysicianParentsCourt-appointed surrogate, as designated under the Uniform Anatomical Gift ActRATIONALE: A parent or legal guardian may give permission for organ donation. A member of the clergy can't gi ve permission for organ donation;however, a family member may see the clergy's guidance in ma ing this decision. The physician may only as the family to consi der organ donation.The Uniform Anatomical Gift Act provides clients and family m embers with the right to choose organ donation, but doesn't allow for designatio n of a

surrogate to ma e decisions related to organ donation.<br>NURSING PROCESS STEP: Implementation<br>CLIENT NEEDS CATEGORY: Safe,effective care environment<br>CLIE NT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: ComprehensionParent s whose first child has celiac disease as the nurse if all of their children wi ll have the disease. To whom should the nurse refer them?Registered dietitianGen etic counselor Certified nurse midwifeSocial wor er RATIONALE: Celiac disease is believed to be a dominantly inherited, inborn error of metabolism. A genetic co unselor could explain about inheriteddisorders, how they're inherited and, when appropriate, provide screening tests. A registered dietitian could provide in-de pth education about a gluten-free diet and help the family adapt the diet to the ir special needs. A social wor er could provide the family with emotional suppor t and help withreferrals for financial problems. A nurse midwife cares for women during pregnancy and childbirth.<br>NURSING PROCESS STEP:Planning<br>CLIENT NEE DS CATEGORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY: Manag ement of care<br>COGNITIVE LEVEL: ComprehensionThe nurse is caring for a schoolage child with cerebral palsy. The child has difficulty eating using regular ute nsils and requires a lot of assistance.Which of the following referrals is most appropriate?Registered dietitianPhysical therapistOccupational therapist Nurse's

aideRATIONALE: An occupational therapist helps physically disabled clients adap t to physical limitations and is most qualified to help a child withcerebral pal sy eat and perform other activities of daily living. A registered dietitian mana ges and plans for the nutritional needs of children withcerebral palsy, but isn' t trained in modifying or fitting utensils with assistive devices. A physical th erapist is trained to help a child with cerebral palsygain function and prevent further disability but not to assist the child in performing activities of daily living. A nurse's aide can help a child eat;however, the nurse's aide isn't tra ined in modifying utensils.<br>NURSING PROCESS STEP: Planning<br>CLIENT NEEDS CA TEGORY: Safe,effective care environment<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: ApplicationAn 18-year-old pregnant woman tells the n urse that she's concerned that she may not be able to ta e care of herself durin g her pregnancy. She statesthat prenatal care is expensive and her job doesn't p rovide insurance. The nurse should recognize that she:may not ta e care of herse lf.may not be fit to ta e care of a child.needs to ta e up a second job.should b e referred to community resources available for pregnant women.RATIONALE: The cl ient needs to now that resources are available to her, and the nurse should hel p her to find those resources. Health care can becostly, but it doesn't necessar ily mean that the client has no interest in caring for herself or her child. Ta ing up a second job doesn't necessarily rectifythis situation.<br>NURSING PROCES S STEP: Implementation<br>CLIENT NEEDS CATEGORY: Safe, effective care environmen t<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: AnalysisTh e nurse is caring for a client with hyperemesis gravidarum who will need close m onitoring at home. When should the nurse begin discharge planning?On the day of dischargeWhen the client expresses readiness to learnWhen the client's vomiting has stoppedOn admission to the hospitalRATIONALE: Discharge planning should begi n when a client is first admitted to the hospital. Initially, discharge planning requires collectinginformation about the client's home environment, support sys tems, functional abilities, and finances. This information is used to determine whatsupport services will be needed. Notifying support services on the day of di scharge won't be sufficient to ensure meeting the client's needs in a timelyfash ion. Waiting until the day of discharge to begin planning is also li ely to caus e the client to become overwhelmed and anxious. Factors such aswhen the client s tops vomiting or expresses readiness to learn shouldn't influence when the nurse begins discharge planning.<br>NURSINGPROCESS STEP: Planning<br>CLIENT NEEDS CAT EGORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY:Management o f care<br>COGNITIVE LEVEL: KnowledgeThe parents of a 5-year-old call the clinic to tell the nurse that they thin their child has been abused by her day-care pr ovider. What should the nurseadvise them to do?Ta e the child to the emergency d epartment of the local hospital.Schedule an immediate appointment with their hea lth care provider.Call the child protective services to file a complaint.Tal to their attorney to file charges against the accused.RATIONALE: Because more info rmation needs to be obtained from the child and family, an immediate appointment is most appropriate. It's unclear what type of abuse the parents are concerned about. Ta ing the child to the emergency department would be appropriate if the child had been sexuallyabused within the past few hours or if the child needed i mmediate treatment for trauma. Calling child protective services is appropriate but isn't the firstaction to ta e; neither is tal ing to an attorney.<br>NURSING PROCESS STEP: Planning<br>CLIENT NEEDS CATEGORY: Safe, effective careenvironmen t<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: Applicatio nThe nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which of the following behaviorswould be most worrisome and should be brought to the attention of the nurse-manager?The nurse eeps communication channels open among herself, the family, physicians, and ot her health care providers.The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions.The nurse wor s with the family mem bers to find ways to decrease their dependence on health care providers.The nurs e has developed teaching s ills to instruct the family members so they can accom plish tas s independently.RATIONALE: When a nurse attempts to influence a family 's decision with her own opinions and values, the situation becomes one of overi

nvolvement on the nurse's part and a nontherapeutic relationship. When a nurse eeps communication channels open, wor s with family membersto decrease their dep endence on health care providers, and instructs family members so they can accom plish tas s independently, she has developed anappropriate therapeutic relations hip.<br>NURSING PROCESS STEP: Analysis<br>CLIENT NEEDS CATEGORY: Safe, effective careenvironment<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LE VEL: AnalysisWhen meeting with parents who will learn that their 3-year-old is s eriously ill, which action demonstrates the nurse's role as collaborator of care ?Provide the parents with information about financial assistance programs.Inform the family of the diagnosis and recently discovered findings.Coordinate the mul tidisciplinary services and provide information about them.Refer and consult wit h other specialties to help in treating the diagnosis.RATIONALE: The nurse can c oordinate care when multiple services are involved, explaining the function of e ach service (social services, casemanagement, counseling services, and so forth) . For instance, providing parents with information about financial assistance pr ograms is theresponsibility of social services. Informing the family of the diag nosis and recently discovered findings is a physician's responsibility, as are r eferring

and consulting with other specialties.<br>NURSING PROCESS STEP: Implementation<b r>CLIENT NEEDS CATEGORY: Safe, effective careenvironment<br>CLIENT NEEDS SUBCATE GORY: Management of care<br>COGNITIVE LEVEL: ComprehensionIn planning a presenta tion that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a n urse should emphasize its effect on:institutional resources.standards of practic e.client-care quality.nursing recruitment.RATIONALE: Client-care quality should always be the first consideration when proposing a change in care provision. Ins titutional resources,standards of practice, and nursing recruitment will all inf luence the decision but none as much as client-care quality should.<br>NURSING P ROCESSSTEP: Planning<br>CLIENT NEEDS CATEGORY: Safe, effective care environment< br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: KnowledgeThe employer of a client on the psychiatric unit calls the nursing station inquirin g about the client's progress. The nurse doesn't now if the client hasgiven con sent to allow the staff to give information out to callers on the phone. Which o f the following would be the nurse's best response?"I'm not permitted to discuss her progress.""I'll give you the name and telephone number of her physician.""I 'll have her call you.""I can't confirm whether your employee is a client here." RATIONALE: The nurse's release of information to the client's employer without t he client's consent is a breach of confidentiality. The stigmaassociated with ps ychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing anyinformation about the cl ient, including whether she's a client in the hospital.<br>NURSING PROCESS STEP: Implementation<br>CLIENT NEEDSCATEGORY: Safe, effective care environment<br>CLI ENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: ApplicationBased o n multiple referrals, the nurse determines that childhood injuries are increasin g in the community in which she practices. The first step thenurse would ta e in developing an educational program is:assessing for a decrease in referrals foll

owing a pediatric safety class.assessing the strengths and needs of the communit y while identifying barriers to learning.choosing a health promotion or health b elief model as a framewor .developing and implementing a specific plan to decrea se childhood injuries.RATIONALE: Following the identification of a learning need , the first step is to assess the strengths and needs of the community while ide ntifying barriers to learning.<br>NURSING PROCESS STEP: Planning<br>CLIENT NEEDS CATEGORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY: Managem ent of care<br>COGNITIVE LEVEL: AnalysisA registered nurse who usually wor s on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is shortstaffed and needs additional help to care for the c lients. The nurse has never wor ed in the CCU. Which of the following responses is the mostappropriate nursing action?Call the hospital lawyer.Report to the CCU and identify tas s that she feels she can safely perform.Spea to the nursing s upervisor.Refuse to go to the CCU.RATIONALE: When the nurse is placed in this si tuation, the most appropriate action is to set priorities and identify potential areas of harm to theclient. Reassignment to another nursing area is an acceptab le legal practice used by hospitals to meet their staffing needs. A nurse can't legally refuse to be reassigned unless there's a specific clause in her union co ntract.<br>NURSING PROCESS STEP: Implementation<br>CLIENT NEEDSCATEGORY: Safe, e ffective care environment<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COG NITIVE LEVEL: ApplicationA nurse-manager is explaining the unit's performance im provement (PI) program to a newly hired nurse. Which of the following should she include asone of the primary purposes of the PI program?Evaluation of client ou tcomesEvaluation of staff member performanceImprovement in the efficiency of car ePreparation for accreditationRATIONALE: PI programs ensure that the best care i s delivered to clients. This can be measured by evaluating client outcomes. Staf f performanceevaluations focus on staff, not client outcomes. Improvement in the efficiency of care may be an aspect of quality care but it isn't the goal. Alth ough PIis one component required for accreditation, the goal is to ensure that t he best care is delivered, not to ensure accreditation.<br>NURSING PROCESSSTEP: Planning<br>CLIENT NEEDS CATEGORY: Safe, effective care environment<br>CLIENT NE EDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: ApplicationTwo family me mbers 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?Call security to come and intervene.Remove the child from the room.As one of the family members to leave the room.Try to reason with both family members.RATIONALE: The first action woul d be to protect the child by removing him from the room. Calling security is nec essary but only after ensuring thesafety of the child. As ing one of the family members to leave the room or reasoning with them would be ineffective at this po int and may evenescalate the situation.<br>NURSING PROCESS STEP: Implementation< br>CLIENT NEEDS CATEGORY: Safe, effective careenvironment<br>CLIENT NEEDS SUBCAT EGORY: Management of care<br>COGNITIVE LEVEL: ApplicationThe nursing supervisor is called to the emergency department to assist with a 10-month-old infant with injuries consistent with child abuse. Thenursing supervisor confers with the eme rgency department physician. To whom must she report the incident?A social wor e r The medical director of the emergency departmentA Children's Protective Servic es (CPS) representativeA public health nurseRATIONALE: Suspected child abuse mus t be reported to a CPS representative. Reporting a potential abuse doesn't indic ate guilt, only suspicion or ris . The CPS and the judicial system will follow t he correct legal process to establish the need for prosecution and counseling.<b r>NURSINGPROCESS STEP: Implementation<br>CLIENT NEEDS CATEGORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY:Management of care<br>COGNITIVE LEV EL: ApplicationThe nurse-manager has noticed a sharp increase in the mediation e rrors with I.V. antibiotics over the last month. She discusses the situation wit h eachnurse involved. What other action should she ta e?Document it on their eva luation.As them to attend inservice training for administration of I.V. medicat ions.Report them to the supervisor.Report the incidents to the hospital attorney .

RATIONALE: Identification of causes of medication errors requires in-service edu cation to inform the staff of strategies to decrease these errors.Errors are fre quently the result of systemic problems that can be identified and rectified thr ough problem-solving techniques and changes in procedures. Documenting or report ing the situation wouldn't directly assist the nurses in eliminating errors. Rep orting the incidents to the hospitalattorney isn't necessary.<br>NURSING PROCESS STEP: Analysis<br>CLIENT NEEDS CATEGORY: Safe, effective careenvironment<br>CLI ENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: ApplicationWhen re porting to the surgeon that a chest tube is malfunctioning, the nurse is ordered to reposition the tube and obtain a chest radiograph. The nurseshould:inform th e surgeon this isn't within her scope of practice.report the surgeon to the Ethi cs Committee.report the surgeon to the nursing supervisor.follow the order as re quested by the surgeon.RATIONALE: Initially, the nurse needs to inform the surge on that the tas is outside the scope of nursing practice. If the surgeon still requests theactivity, the nurse should refuse to perform the tas and should fol low the chain of communication for reporting unsafe practice according to thehos pital's policy. The nurse must not comply with any order that goes beyond the sc ope of nursing practice.<br>NURSING PROCESS STEP:Assessment<br>CLIENT NEEDS CATE GORY: Safe, effective care environment<br>CLIENT NEEDS SUBCATEGORY: Management o f care<br>COGNITIVE LEVEL: KnowledgeAn Iranian mother and father admit their 14month-old son to the pediatric unit for treatment of leu emia. When the female p ediatric oncologist, whoisn't Muslim, introduces herself, they became uncooperat ive and refused treatment. The nurse should be aware that this change of behavio r is probablyrelated to:the gender of the physician.fear of being accused of chi ld abuse and neglect by an authority figure.religious barriers that prevent the family from accepting care from someone who isn't of their religion.aggressivene ss of Middle Easterners.RATIONALE: The Iranian tradition of male authority is st ill strong. Accepting a woman ma ing life-and-death decisions for their son may be verydifficult for these parents. Discussing with the parents other options, s uch as the idea of turning the case over to a male Muslim oncologist, would beap propriate. The gender issue is a stronger cultural factor than the religious dif ference. There's no basis to relate the parents' behavior to fear of beingcharge d with abuse or neglect. Attributing the behavior to Middle Eastern aggressivene ss reflects a stereotype, not a culture value.<br>NURSINGPROCESS STEP: Assessmen t<br>CLIENT NEEDS CATEGORY: Safe, effective care environment<br>CLIENT NEEDS SUB CATEGORY:Management of care<br>COGNITIVE LEVEL: KnowledgeWhich of the following clients would be a priority for the nurse to evaluate when assuming responsibili ty for their care at the beginning of the dayshift?The client who had a total la ryngectomy the previous dayThe client with diabetes who had a fasting blood gluc ose of 150 mg/dlAn elderly client who has Alzheimer's disease and periods of con fusionA client with a pneumothorax who had a chest tube inserted earlier in the dayRATIONALE: Based on the information provided, the client who is on day 1 afte r a total laryngectomy would be the priority client for the nurse toevaluate. Th is client is at ris for impaired respiratory status and should be monitored clo sely. Clients with acute conditions that can affect their respiratory status are a high priority for nursing care.<br>NURSING PROCESS STEP: Planning<br>CLIENT N EEDS CATEGORY: Safe, effectivecare environment<br>CLIENT NEEDS SUBCATEGORY: Mana

gement of care<br>COGNITIVE LEVEL: AnalysisThe nurse receives report on the assi gned clients at the beginning of the evening shift. Which of the following clien ts should the nurse plan to assessfirst?A client who is scheduled for a cardiac catheterization in the morning and is visiting with his familyA client receiving an I.V. infusion via a central line at 60 ml/hour with 400 ml remaining in the I.V. fluid bottleA young male client with chest tubes placed for treatment of a pneumothorax who is resting comfortablyAn elderly client with pneumonia who has periods of confusionRATIONALE: Because of the elderly client's diagnosis of pneu monia and periods of confusion, there's a potential for client injury and decrea sed levelsof oxygenation. The nurse should assess this client first.<br>NURSING PROCESS STEP: Planning<br>CLIENT NEEDS CATEGORY: Safe,effective care environment <br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: AnalysisTwo nurses are in the cafeteria having lunch in a quiet, secluded area. There's a p erson sitting at a table near to them. During lunch, the nurses discuss aclient who was physically abused. Later, that same person is visiting the client and as s the client questions about the physical abuse. The clientdiscovers that the v isitor overheard the nurses tal ing about the abuse situation and is emotionally harmed. The ramifications associated with thenurses' discussion about the clien t are most appropriately associated with which of the following? None, because t hey were in a quiet, secluded area.They can be charged with slander.They can be charged with libel. None because the person who overheard is a friend of the cli ent.RATIONALE: Defamation occurs when information is communicated to a third par ty that causes damage to someone else's reputation either in writing(libel) or v erbally (slander). The most commonexamples are giving out inaccurate or inapprop riate information from the medical record; discussing clients, families, or visi tors in public areas; or spea ing negatively about cowor ers. This situation can cause emotional harm to the client, and the nurses could be charged with slande r. Thissituation also violates the client's right to confidentiality.<br>NURSING PROCESS STEP: Planning<br>CLIENT NEEDS CATEGORY: Safe,effective care environmen t<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: Applicatio nThe registered nurse as s the licensed practical nurse (LPN) to change the colo stomy bag on a client. The LPN tells the registered nurse that althoughshe recei ved inservice training for this procedure, she never performed it on a client. W hat's the most appropriate action for the registered nurse tota e?Request that t he LPN review the procedure in the hospital manual.Request that the LPN review t he materials from the inservice before performing the procedure.Perform the proc edure with the LPN.Request that another LPN observe the procedure when it's perf ormed.RATIONALE: The registered nurse must remember that even though a tas may be delegated to someone, the nurse who delegates maintainsaccountability for the overall nursing care of the client. The RN is responsible for ensuring that com petent and accurate care is delivered to the client.Requesting that another LPN observe the procedure doesn't ensure that the procedure will be done correctly. Because this is a new procedure for thisLPN, the registered nurse should accompa ny the LPN, provide guidance, and answer questions after the procedure.<br>NURSI NG PROCESS STEP:Implementation<br>CLIENT NEEDS CATEGORY: Safe, effective care en vironment<br>CLIENT NEEDS SUBCATEGORY: Management of care<br>COGNITIVE LEVEL: Ap plication

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