Deck 3 Module 49

Question 1

A student nurse administers a medication to the wrong client while the instructor is with another student. Which statement by the instructor is most appropriate in this situation?
A) “You have placed the nursing student program in danger.”
B) “You may be sued by the hospital for the extra care cost to the client.”
C) “You are expected to practice like a licensed nurse.”
D) “You have set a bad example for the other students.”

Answer 1

C) “You are expected to practice like a licensed nurse.”

Rationale:

A nursing student is held to the standard of conduct of an experienced, licensed professional nurse. Students are required to know the standards and to follow them. Hospitals do not generally sue nurses to recover money for extended care due to an error. It is not likely that the teaching program is in danger, as people do make mistakes and hospitals do rely on nursing schools to help provide care to clients. It is not likely that the other students are apt to follow the example of a student who fails to follow policy.

Question 2

The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? Select all that apply.
A) Client fell getting out of bed because the call light was not used.
B) Client name band was checked prior to providing all medications.
C) Client’s morning medications were administered in the early afternoon.
D) Client states not understanding activity restrictions and wound eviscerated.
E) Client documentation did not include appearance of infiltrated IV site.

Answer 2

A) Client fell getting out of bed because the call light was not used.
B) Client name band was checked prior to providing all medications.
C) Client’s morning medications were administered in the early afternoon.
D) Client states not understanding activity restrictions and wound eviscerated.

Rationale:

Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client’s healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care.

Question 3

A nurse working on a medical-surgical unit wants to ensure care is provided within the standard of nursing care. Which actions by the nurse are appropriate? Select all that apply.
A) Analyze the position description.
B) Review and become familiar with the policy and procedure manual.
C) Question the value of collaborating with other disciplines.
D) Review applicable state nurse practice act and administrative rules.
E) Adhere to national standards of practice and care.

Answer 3

A) Analyze the position description.
B) Review and become familiar with the policy and procedure manual.
D) Review applicable state nurse practice act and administrative rules.
E) Adhere to national standards of practice and care.

Rationale:

Nurses are expected to demonstrate competence within multiple areas of their professional role, including collaboration with the entire care team. The nurse’s specific job description will contribute to defining the standard of care. Employers can limit but not expand the scope of practice, and the nurse will be held to functioning within the scope of employment. Agency policies and procedures serve in defining the standard of care. The applicable state nurse practice act and administrative rules form the basis of the standard of care to which each nurse is held. A primary source for defining the standard of care is the prevailing national nursing standards. Nurses who follow national standards of practice and standards of care will provide their clients with the best care possible and be far less likely to commit any unintentional act that may rise to the level of malpractice.

Question 4

The nurse observes a healthcare provider discussing an operative procedure with a client and determines that informed consent was achieved. Which information was included in the informed consent process? Select all that apply.
A) The provider’s disapproval if the surgery is not performed
B) The health problem that requires surgery
C) The purpose of the surgery
D) The expectations of the surgery
E) Outcome if surgery is not performed

Answer 4

B) The health problem that requires surgery
C) The purpose of the surgery
D) The expectations of the surgery
E) Outcome if surgery is not performed

Rationale:

For informed consent to be achieved, the client should receive the following information: the diagnosis or condition that requires treatment, purposes of the treatment, what the client can expect to feel and experience, intended benefits of the treatment, risks, and what could occur if the surgery is not performed or if alternatives to the treatment are chosen. To give informed consent voluntarily, the client must not be coerced in any manner. If the client provides consent due to fear of disapproval by a healthcare provider, such consent is not considered to be voluntary. Coercion of any kind invalidates the consent.

Question 5

A client is receiving care in the hospital for life-threatening injuries sustained in a motor vehicle crash and is taken immediately to surgery. There is no family available to provide consent; however, the client’s medical record is available and reviewed by the nurse. Which treatments are inappropriate in this situation? Select all that apply.
A) Emergency surgery
B) Treatment that was previously refused
C) Treatment that violates religious beliefs
D) Medications to treat the injury
E) Experimental medications for a research study

Answer 5

B) Treatment that was previously refused
C) Treatment that violates religious beliefs
E) Experimental medications for a research study

Rationale:

In most states, the law assumes an individual’s consent to medical treatment when the person is in imminent danger of loss of life or limb and unable to give informed consent. In other words, the emergency doctrine assumes that the individual would reasonably consent to treatment if able to do so. This doctrine serves as a guiding principle that permits healthcare providers to perform potentially life-saving procedures under circumstances that make it impossible or impractical to obtain consent. Treatment that was previously refused or violates the client’s documented religious beliefs is not appropriate. Experimental medications that are being initiated in conjunction with a research study are also not appropriate.

Question 6

A 16-year-old client has requested that she be examined and receive counseling without her parents being present. Which response demonstrates a correct response to this request?
A) The nurse asks the client’s parents if this is okay with them.
B) The nurse agrees but still informs the parents immediately of everything they did not witness.
C) The nurse strongly urges the client to reconsider this request to receive the best possible care.
D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved.

Answer 6

D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved.

Rationale:

Adolescent clients may wish to be examined or receive counseling separate from their parents. The nurse should make every effort to honor this request, though doing so may lead to confrontation with the parents. Understanding state statutes and organizational policy related to adolescent confidentially is essential when situations such as this arise. When providing confidential care to adolescents, the nurse should encourage adolescents to consider involving parents or guardians in their decision making. The nurse should make it clear that this is a suggestion and not a requirement for receiving care. The nurse should not clear this request with the parents, involve the parents anyway, or make it sound as though competent care depends on the adolescent reconsidering her request.

Question 7

Which action demonstrates correct reporting of suspected child abuse?
A) The nurse includes the entirety of the client’s medical record.
B) The nurse compiles a report with all pertinent information that is factually true.
C) The nurse recommends that the organization report the abuse to state authorities.
D) The nurse reports only information the client has authorized for release.

Answer 7

B) The nurse compiles a report with all pertinent information that is factually true.

Rationale:

Reports should be complete and accurate and should be made according to the policy of the organization for which the nurse works. In addition to reporting the abuse within the organizational framework, the nurse should personally report the abuse to the proper authorities. When abuse is reported, all pertinent information in the client’s medical record (not simply the entire record) is required by law to be disclosed to the reporting agency. As such, reporting abuse or suspected abuse represents an exception to client confidentiality rules.

Question 8

A client newly diagnosed with diabetes mellitus tells the nurse that the prescribed diet does not provide enough variation of choice. It is against the state’s nurse practice act for a nurse to order a diet for the client. Which response by the nurse is most appropriate?
A) “I will bring you a different menu.”
B) “I will ask my manager to talk with the dietitian.”
C) “Let’s look at your diet and see what type of variety we can find.”
D) “I will notify the dietary department to change your diet.”

Answer 8

C) “Let’s look at your diet and see what type of variety we can find.”

Rationale:

A nurse practice act (NPA) is a series of state statutes that define the scope of practice, standards for education programs, licensure requirements, and grounds for disciplinary actions. The law provides a framework for establishing nursing actions in the care of clients. It is against most states’ nurse practice acts for the nurse to order a diet for the client. The nurse is allowed to assist the client to choose appropriate foods as ordered by the physician. The nurse cannot notify the dietary department or enlist the assistance of a manager to change the diet with a healthcare provider prescription. Providing the client with another menu will not help the client choose foods within the prescribed diet.

Question 9

A nurse educator is teaching a group of nursing students about the function of the state board of nursing. Which information will the educator include in the teaching session? Select all that apply.
A) Creating the NCLEX-RN examination
B) Defining professional standards
C) Investigating violations of the nurse practice act
D) Suspending or revoking licenses
E) Finding drug treatment centers for impaired nurses

Answer 9

B) Defining professional standards
C) Investigating violations of the nurse practice act
D) Suspending or revoking licenses

Rationale:

Boards of nursing oversee nursing licensure by defining professional standards, investigating violations of the nurse practice act, sanctioning those who violate the nurse practice act, and suspending or revoking licenses. The National Council for the State Boards of Nursing creates the NCLEX-RN examinations. The state board of nursing is not responsible for finding treatment programs for drug-impaired nurses.

Question 10

The nurse receives a notice that the state board of nursing has become a member of the Nurse Licensure Compact. How would this change in the state board of nursing structure influence the nurse’s ability to practice nursing? Select all that apply.
A) The nurse can only practice nursing in the residing state.
B) The nurse can practice nursing in other states within the compact.
C) The nurse is accountable to the state in which the nurse and clients reside.
D) The nursing license will become similar to having a driver’s license.
E) The nurse has to obtain an additional license.

Answer 10

B) The nurse can practice nursing in other states within the compact.
C) The nurse is accountable to the state in which the nurse and clients reside.
D) The nursing license will become similar to having a driver’s license.

Rationale:

The mutual recognition model of nurse licensure allows a nurse to have a single license that confers the privilege to practice in other states that are part of the Nurse Licensure Compact. The nurse is held accountable for following the laws and rules of the state in which the nurse practices or where the client is located. It is similar to the driver’s license model: A single license to drive is issued in the state of primary residency, but this license also allows the privilege to drive in other compact states. Multistate licensure privilege means the authority to practice nursing in another state that has signed an interstate compact. It is not an additional license.

Question 11

The nursing instructor asks a student to explain why the American Board of Managed Care Nursing (ABMCN) is an example of a certification program. How should the student respond?
A) It formally recognizes nurses who have achieved a high standard of practice in managed care.
B) It provides a process for recognizing the professional competence of individuals who pass the program.
C) It investigates and adjudicates cases of professional negligence.
D) It lists the state requirements for a nursing professional to achieve licensure.

Answer 11

B) It provides a process for recognizing the professional competence of individuals who pass the program.

Rationale:

Although a nursing license grants the legal privilege to practice, credentialing is the formal identification of professionals who meet predetermined standards of professional skill or competence. The federal government has used the term certification to define the credentialing process by which a nongovernmental agency or association recognizes the professional competence of an individual who has met certain predetermined qualifications specified by the agency or association. The American Board of Managed Care Nursing is one such organization. Formally recognizing nurses who have achieved a high standard of practice in managed care is an example of credentialing. It is not the ABMCN’s role to investigate and adjudicate cases of professional negligence or to simply list requirements for nursing professionals to achieve licensure.

Question 12

Which of the following is a licensure examination developed by the National Council of State Boards of Nursing (NCSBN) for state and territory boards of nursing (BONs) to implement as part of their requirements for licensure?
A) National Council Licensure Examination for Registered Nurses (NCLEX-RN)
B) National Nurse Aide Assessment Program (NNAAP)
C) Medication Aide Certification Examination (MACE)
D) Nursing Workforce Diversity (NWD) program

Answer 12

A) National Council Licensure Examination for Registered Nurses (NCLEX-RN)

Rationale:

The National Council of State Boards of Nursing (NCSBN) has developed two licensure examinations, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and the National Council Licensure Examination for Practical Nurses (NCLEX-PN), for state and territory BONs to implement as part of their requirements for licensure. The NCSBN also offers two additional examinations: the National Nurse Aide Assessment Program (NNAAP) and the Medication Aide Certification Examination (MACE). The Nursing Workforce Diversity (NWD) program is not a licensure examination.

Question 13

Which statement exemplifies the ultimate accountability of nursing students for their actions?
A) “State regulatory bodies have the ultimate responsibility for my actions.”
B) “The client’s perception of the care I give determines the correctness of my actions.”
C) “I am responsible for my own actions, correct or incorrect.”
D) “No one may judge my actions as correct or incorrect other than me.”

Answer 13

C) “I am responsible for my own actions, correct or incorrect.”

Rationale:

Each nurse practice act (NPA) addresses the duties and responsibilities of nursing students in that state. Typically, this includes language that allows nursing students the privilege to practice nursing without a license while engaged in the clinical practicum of an approved nursing education program under the supervision of qualified faculty. Nursing students have the ultimate responsibility (accountability for their actions that includes the obligation to answer for an act done and to repair any injury one may have caused) for their own actions. This responsibility does not rest ultimately with the state and does not depend solely on client perceptions. Responsibility does not mean that no one else but the nursing student may judge the student’s actions.

Question 14

A client with terminal cancer has signed an advance directive indicating that no parenteral nutrition or hydration will be implemented. For several days the client has refused food and fluids, pushing the caregiver’s hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is “starving to death.” Which actions by the nurse are appropriate? Select all that apply.
A) Take the case to the hospital’s ethics committee.
B) Honor the client’s refusal of parenteral nutrition and hydration.
C) Talk to the healthcare provider so the family’s wishes can be acted upon.
D) Help the family come to terms with the situation.
E) Honor the family’s wishes and have them sign a consent form.

Answer 14

B) Honor the client’s refusal of parenteral nutrition and hydration.
D) Help the family come to terms with the situation.

Rationale:

A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. This position is supported by the ANA’s Code of Ethics for Nurses, through the nurse’s role as a client advocate and through the moral principle of autonomy. Clients, not their families, should make decisions about their own healthcare and treatment. The physician may or may not be involved, but would not disregard the client’s refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.

Question 15

A client who sustained a traumatic brain injury several weeks ago is in a chronic vegetative state and is no longer competent to make healthcare decisions. Who should the nurse expect to make care decisions for this client?
A) The physician
B) The client’s spouse
C) Social services
D) The agent named in the durable power of attorney

Answer 15

D) The agent named in the durable power of attorney

Rationale:

The nurse, recognizing that the client is no longer competent, should follow whatever hospital policy is in place for contacting the agent named in a durable power of attorney for healthcare. The physician is not the appropriate individual to make decisions for the client. Social services may be the department that would contact the agent of a durable power of attorney, but social services would not be that power. In the case of an incompetent client, the spouse would be the agent of the durable power of attorney only if the court appointed the spouse.

Question 16

After discussing advance directives during a home visit, an older adult client decides to prepare documents for future care needs. Which actions by the nurse are appropriate in this situation? Select all that apply.
A) Telling the client that changes to the advance directive can be made at any time
B) Telling the client that it is not necessary to make decisions about healthcare needs in the future
C) Giving a copy of the advance directives to the client’s adult children
D) Educating the client about the purpose and types of life-sustaining measures
E) Having the client name an individual to be responsible for care decisions

Answer 16

A) Telling the client that changes to the advance directive can be made at any time
C) Giving a copy of the advance directives to the client’s adult children
D) Educating the client about the purpose and types of life-sustaining measures

Rationale:

The nurse should explain that if a decision is made on an advance directive, the decision can be changed. Clients should be instructed to provide a copy of their advance directives to their next of kin. The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures and provide teaching on these measures if necessary. An advance directive does not mean that the client does not need to make any future decisions about healthcare. An individual to be responsible for care decisions is a durable power of attorney for healthcare and may or may not be included when creating an advance directive.

Question 17

A nurse educator on an oncology unit is teaching staff nurses about advance directives. Which elements will the nurse include in the teaching session? Select all that apply.
A) The surrogate decision maker has the authority to consent to any medical treatment or diagnostic procedure.
B) The surrogate decision maker has the authority to consent to only lifesaving medical treatments.
C) The surrogate decision maker has the authority to authorize admission only to medical facilities and not long-term care facilities.
D) The surrogate decision maker has the authority to have access to all medical records.
E) The surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure.

Answer 17

A) The surrogate decision maker has the authority to consent to any medical treatment or diagnostic procedure.
B) The surrogate decision maker has the authority to consent to only lifesaving medical treatments.
E) The surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure.

Rationale:

The surrogate decision maker has the authority to have access to all medical records and to consent to any medical treatment or diagnostic procedure. Furthermore, the surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure. The surrogate decision maker has the authority to authorize admission not only to medical facilities but also to long-term care facilities.

Question 18

The nurse on the medical unit is admitting a client. When the nurse asks the client about advance directives, the client states, “I have a living will.” Which is the purpose of a living will?
A) Provides specific instructions about type of medications the client requires to sustain life
B) Provides specific instructions about what medical treatment the client does not want in the event they can no longer make decisions for themselves
C) Provides specific instructions about who will make healthcare decisions if the client cannot
D) Provides specific instructions about how decisions are to be made if the client is unable to make the decisions

Answer 18

B) Provides specific instructions about what medical treatment the client does not want in the event they can no longer make decisions for themselves

Rationale:

There are two types of advanced directives, the living will and the durable power of attorney for healthcare. The living will provides specific instructions about what medical treatment the client chooses to omit or refuse. The durable power of attorney for healthcare identifies who will be making healthcare decisions if the client cannot. Living wills do not dictate medication requirements or how decisions are to be made if the client cannot make them.

Question 19

The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the admission process, the client states, “I do not want to be put on a ventilator because I had to watch my mother die on a ventilator. I want information on making out a living will.” When planning care for this client, which intervention is the most appropriate?
A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so.
B) Encourage the client to allow for mechanical ventilation.
C) Educate the client on the purpose of mechanical ventilation.
D) Refer the client to a therapist to deal with the death of her mother.

Answer 19

A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so.

Rationale:

Although it is appropriate to educate the client on mechanical ventilation, the client asked for information on making out a living will. It would be most appropriate at this time for the nurse to educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so. The nurse should not attempt to convince the client to allow for medical treatment. The nurse may educate the client on a medical treatment, but that does not address the client’s desire for a living will. There is no indication that this client needs therapy.

Question 20

A client on a medical-surgical unit experiences a code blue situation unexpectedly. The emergency situation has ended and the client survived. The nurses are breaking for lunch and plan to process their feelings about the emergency. Which action by the nurses will facilitate this?
A) Discussing the event outside the hospital
B) Asking management for the use of a private room to debrief
C) Talking while riding in the staff elevator
D) Debriefing about the situation at home

Answer 20

B) Asking management for the use of a private room to debrief

Rationale:

To comply with HIPAA, nurses cannot discuss events involving clients in any setting where the conversation can be heard by others, so a private room would be the best place to debrief. The nurses must also guard against other health professionals not directly involved with the client overhearing their discussion; consequently, a staff elevator is not acceptable. Discussing the event outside the hospital is inappropriate because anyone could overhear the conversation. This would also preclude nurses from discussing client care in the home.

Question 21

The nurse is caring for a client on a medical-surgical unit that has just implemented the electronic medical record for client documentation. The client asks the nurse about the facility’s computerized system for keeping client information, especially in regard to confidentiality. Which is the best response by the nurse?
A) “I can see why you’re worried, with all the computer hackers out there these days.”
B) “Our system was designed with a lot of input from nursing staff.”
C) “Electronic medical records are kept in accordance with the HIPAA Privacy Rule.”
D) “Don’t worry; your information is always safe.”

Answer 21

C) “Electronic medical records are kept in accordance with the HIPAA Privacy Rule.”

Rationale:

The Privacy Rule protects all “individually identifiable health information” held or transmitted in any form or media, whether electronic, paper, or oral. The rule calls this information protected health information and delineates it further to include information that identifies the individual (e.g., name, address, birth date, and Social Security number) or for which a reasonable basis exists to believe the information can be used to identify the individual. Information in a computer data system may not always be safe, and it would be inappropriate for the nurse to say this. Nurses need to be involved with the design, implementation, and evaluation of electronic medical records to maximize their use and effectiveness, but this does not ensure security. Reminding the client that there is indeed cause for privacy concerns is not as therapeutic as explaining that the system requires a password.

Question 22

Which action protects the client’s confidentiality?
A) The nurse discusses details of a client’s case with family members she expects will tell no one else.
B) The nurse doesn’t reveal outside the healthcare team that he was involved with the treatment of a famous client.
C) The nurse thinks HIPAA procedures for her facility are too restrictive to enable necessary sharing of information.
D) The nurse discusses clients only with other employees of the healthcare facility where he works.

Answer 22

B) The nurse doesn’t reveal outside the healthcare team that he was involved with the treatment of a famous client.

Rationale:

Confidentiality refers to the assurance the client has that private information will not be disclosed without his or her consent. Confidentiality applies both to the nature of the information the nurse obtains from the client and to how the nurse treats client information once it has been disclosed to the nurse. The nurse who does not reveal he participated in the treatment of a famous client is protecting that client’s confidentiality. The nurse discussing the details of a client’s case with family members and the nurse discussing clients with any other employees of his facility are violating client confidentiality. The nurse who thinks her facility’s HIPAA procedures are too restrictive is neither protecting nor violating confidentiality.

Question 23

The nurse is asked to participate on a committee to ensure that no breaches of client confidentiality occur when providing care. Which actions help ensure client confidentiality when providing care? Select all that apply.
A) Withholding private information from other staff unless needed for care
B) Sharing the name and diagnosis of clients upon request
C) Discussing client care with nurses on other units
D) Restricting the discussion of client care to the report room
E) Reviewing the client’s care needs with a designated health insurance agent

Answer 23

A) Withholding private information from other staff unless needed for care
D) Restricting the discussion of client care to the report room
E) Reviewing the client’s care needs with a designated health insurance agent

Rationale:

The nurse has the responsibility to keep client information private and confidential. Actions that ensure client confidentiality include only sharing information with staff who are directly involved in care and restricting discussion regarding client care to the report room or other areas that are secure. Client names and diagnoses should only be shared with those who are directly providing care. The nurse is able to review the client’s care needs with the designated health insurance agent.

Question 24

The Health Insurance Portability and Accountability Act (HIPAA) was created in part to
A) exclude clients with preexisting conditions from healthcare insurance coverage.
B) designate special rights for individuals who lose other health coverage.
C) promote medical underwriting in group plans.
D) relax the rules for disclosure of protected health information.

Answer 24

B) designate special rights for individuals who lose other health coverage.

rationale:

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was enacted by Congress to minimize the exclusion of preexisting conditions as a barrier to healthcare insurance, designate special rights for individuals who lose other health coverage, and eliminate medical underwriting in group plans. The act includes the Privacy Rule, which creates a national standard for the disclosure of private health information. This rule affects all healthcare providers as well as health insurance plan providers, and it defines, not relaxes, the rules for disclosure of protected health information.

Question 25

Which of the following should the nurse understand to be health information not protected under the HIPAA Privacy Rule?
A) A client’s Social Security number, birthdate, and mailing address
B) A description of the symptoms of an illness the client has that does not reference the client in any way
C) The details of a client’s visit to a medical office including the diagnosis rendered
D) How much the client owes for a treatment rendered to the client

Answer 25

B) A description of the symptoms of an illness the client has that does not reference the client in any way

Rationale:

Protected health information includes information that identifies the individual (e.g., name, address, birth date, and Social Security number) or for which a reasonable basis exists to believe the information can be used to identify the individual as it relates to the individual’s past, present, or future physical or mental health or condition; the provision of healthcare to the individual; or the past, present, or future payment for the provision of healthcare to the individual. A mere description of the symptoms for an illness that does not reference the client in any way is not protected health information.

Question 26

While making rounds on the night shift, a nursing supervisor notes that a 73-year-old client under observation following a myocardial infarction has multiple visible bruises on the arms and legs. The supervisor suspects abuse because nothing in the client’s chart suggests this client should have sustained these injuries. This state’s good faith immunity applies in cases of suspected abuse not only of children but also of older adults or adults with disabilities. Which action has the highest priority for the nursing supervisor in this situation?
A) Notify authorities regarding the suspected abuse.
B) Do nothing about the situation.
C) Notify the security department.
D) Ask a shift nurse about the source of the injuries.

Answer 26

A) Notify authorities regarding the suspected abuse.

Rationale:

States also have specific laws pertaining to the mistreatment of adults and older adults. These laws may be similar to those that govern the abuse and neglect of children. For example, many states generally offer good faith immunity to individuals who report suspected abuse or neglect of an older adult or an adult with a disability. This immunity would apply in the case of this client. Security is not the appropriate department to notify unless the injuries were sustained at work. Questioning a shift nurse about the source of the injuries is fine to do but should not replace reporting the injuries to the appropriate authorities, which should be done in this case because the supervisor suspects abuse.

Question 27

During an assessment of a child in the urgent care clinic, the nurse notes that the child has a swollen and split lip. When asking the parent how the child’s lip injury occurred, the parent responds, “We are here for my child’s ear not my child’s lip.” Which is the rationale for reporting this incident?
A) The child reports that a parent caused the injury.
B) The lip injury is unrelated to the ear infection.
C) The nurse can be sued if there is no abuse.
D) Suspected abuse must be reported.

Answer 27

D) Suspected abuse must be reported.

Rationale:

Suspected child abuse must be reported by law. Healthcare personnel are protected by good faith immunity because the ultimate goal is the protection of the child. The lip injury being unrelated to the ear infection is not a reason to report the injury. Most children will not accuse an abuser; rather, they generally protect the abuser. The reason for the law is that experts can assess the situation and determine if abuse has occurred. The nurse is protected by good faith immunity.

Question 28

An adolescent client with a sexually transmitted infection (STI) says to the nurse, “Promise you won’t tell my parents about my condition.” The agency policy is that all STIs must be reported in accordance with federal and state law. Which action by the nurse is appropriate?
A) Disclosing information to the parents
B) Reporting the STI to the proper authorities
C) Respecting the client’s privacy and confidentiality by not mentioning or reporting the STI
D) Telling other nurses in the clinic that the client has an STI

Answer 28

B) Reporting the STI to the proper authorities

Rationale:

In this case, the nurse is required to report information about the client’s STI to the state health department. Because of confidentiality issues, the nurse should not report the STI to the parents or to other nurses not involved in the client’s care.

Question 29

The nurse is in the midst of a complicated client care situation and is not sure what needs to be done with some information. Which healthcare issues must the nurse report to the state? Select all that apply.
A) Amputation of a limb
B) Death of a client
C) Death of a neonate
D) Diagnosis of tuberculosis
E) Kidney transplant

Answer 29

B) Death of a client
C) Death of a neonate
D) Diagnosis of tuberculosis

Rationale:

The term mandatory reporting refers to a legal requirement to report an act, event, or situation that is designated by state or local law as a reportable event. All states mandate the reporting of certain vital statistics, including deaths. Many states also require healthcare providers to report neonatal deaths. Federal and state laws mandate the reporting of communicable diseases such as tuberculosis. Limb amputations and transplants do not need to comply with mandatory reportable events.

Question 30

A nurse who reports suspected child abuse, honestly believing it to have occurred, is not subject to civil or criminal liabilities when the subsequent investigation does not make a determination of abuse. This is called
A) good faith immunity.
B) protection of privacy.
C) breach of confidentiality.
D) criminal malfeasance.

Answer 30

A) good faith immunity.

Rationale:

In every state, healthcare workers are protected from civil or criminal liabilities when they report suspected child abuse in good faith, even if the subsequent investigation does not make a determination of abuse. This is called good faith immunity. This is not protection of privacy, breach of confidentiality, or criminal malfeasance.

Question 31

Which of the following statements describes the nurse’s duty to investigate suspected abuse of a pediatric client before reporting it?
A) The nurse must question a parent or guardian about the suspected abuse.
B) The nurse must personally observe the client being abused.
C) The nurse must identify at least two witnesses who will testify that the client was abused.
D) The nurse does not need to investigate suspected abuse of a pediatric client.

Answer 31

D) The nurse does not need to investigate suspected abuse of a pediatric client.

Rationale:

Regardless of the situation, the nurse is not required to conduct any type of investigation or otherwise confirm that the suspected abuse of a pediatric client has, in fact, occurred. The nurse is required only to have a good faith suspicion based on information disclosed by a client, physical symptoms observed in a client, or the nurse’s personal observations of behavior on the part of a client, colleague, or third party. The nurse is not required, therefore, to question a parent or guardian about the abuse, personally observe the client being abused, or identify witnesses who will testify to the abuse.

Question 32

A nurse educator is planning a class for a group of nursing students regarding risk management. Which information should the educator include in this presentation? Select all that apply.
A) Risk management seeks to prevent harm.
B) Risk management empowers clients.
C) Risk management controls the cost of supplies.
D) Risk management examines past mistakes and identifies potential hazards.
E) Risk management ensures that nurses are truthful.

Answer 32

D) Risk management examines past mistakes and identifies potential hazards.

Rationale:

The major goal of a risk management department is to limit a healthcare agency’s financial and legal risk associated with the delivery of care, particularly in terms of lawsuits, ideally before incidents occur. This involves preventing harm to clients and hospital personnel by examining past mistakes and identifying potential hazards. The cost of supplies, truthfulness of nurses, and empowerment of clients are not goals of risk management.

Question 33

A novice nurse attends a lecture regarding risk management. Which action should the nurse implement to reduce risks in practice?
A) Not discussing errors made
B) Questioning every order that the physician writes
C) Urging the nurse’s organization to purchase liability insurance
D) Storing unused equipment in the halls of the unit

Answer 33

C) Urging the nurse’s organization to purchase liability insurance

Rationale:

Healthcare organizations can use several strategies to minimize risk. One of the most basic strategies is protecting against financial risk by purchasing insurance or by self-insuring. Risk management also entails analyzing errors to determine causes and changing policy to reduce more errors. Nurses should report all errors in an effort to assist in the campaign to reduce medical errors. Storing unused equipment in the hall serves to eliminate risk of contamination but could increase the risk of injury. The nurse does not need to question every order that a physician writes; the nurse is responsible only for questioning orders that may injure clients.

Question 34

The nurse is concerned about the risk involved when implementing healthcare provider prescriptions for a newly admitted client. Which strategies should the nurse consider to reduce this risk? Select all that apply.
A) Question any order written for a postoperative client.
B) Question any order a client questions.
C) Question any order if the client’s condition changes.
D) Question any verbal order.
E) Question any order that is incomplete.

Answer 34

B) Question any order a client questions.
C) Question any order if the client’s condition changes.
E) Question any order that is incomplete.

Rationale:

Nurses can minimize risk by analyzing procedures and medications ordered by the physician. It is the nurse’s responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescribing physician. To protect themselves legally, nurses should question any order a client questions, any order if the client’s condition has changed, and any order that is incomplete. Orders written for postoperative clients do not all need to be questioned. Verbal orders should be recorded accurately to avoid miscommunication, but they do not all need to be questioned.

Question 35

The nursing instructor is evaluating the success of training provided to staff nurses on ways to reduce the incidence of pediatric medication errors. Which observations indicate that training has been effective? Select all that apply.
A) Staff nurses are double-checking medication calculations.
B) Staff nurses are refusing to dilute medications.
C) Staff nurses are using liquid preparations.
D) Staff nurses are asking the pharmacy to prepare the exact doses.
E) Staff nurses are asking each other to validate placement of decimal points.

Answer 35

A) Staff nurses are double-checking medication calculations.
C) Staff nurses are using liquid preparations.
E) Staff nurses are asking each other to validate placement of decimal points.

Rationale:

Children are at a higher risk for medical error than other clients and also may be more vulnerable to harm from errors due to their immature physiology. Reasons for increased medical error among children include miscalculation of doses and amounts and incorrect placement of the decimal point in calculations. Nurses who double-check medication calculations, use liquid preparations, and ask another nurse to validate the placement of the decimal point are demonstrating that the training was effective. The nurses should not be refusing to dilute medications because many preparations require dilution to achieve the small dosages required by infants, and they should not expect the pharmacy to prepare the medications in exact doses.

Question 36

A medication error occurred and the nurse is preparing to complete an incident report. Which information is required to thoroughly complete this report? Select all that apply.
A) Name of client involved in the incident
B) Location where incident report is completed
C) Date and time of the incident
D) Medication involved in the incident
E) Number of hours the nurse was at work before the incident occurred

Answer 36

A) Name of client involved in the incident
C) Date and time of the incident
D) Medication involved in the incident

Rationale:

An incident report is an agency record of an accident or incident occurring within the agency. Incident reports generally include the names and identifying information of any clients and healthcare personnel involved in the incident as well as information on witnesses; the location, time, and date of the incident; and if a medication is involved, the medication’s name and dosage. The location of the incident, not where the incident report itself is completed, should be entered. The number of hours the nurse worked before the incident occurred is not a part of the report.