3. The nursing instructor asks a student to name an example of false imprisonment.

Principles of Delegation NCLEX

• A client with leukemia is being considered for a bone marrow transplant. The

healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing?• nonmaleficence

• Which action by the nurse represents the ethical principle of beneficence?

• The nurse administers an immunization to a child even though it may cause discomfort

• The nursing instructor asks a student to name an example of false imprisonment.

Which of the following situations reflects a violation of this client right?• Tell the client that he or she may not leave the hospital

• A nurse and a nursing assistant enter a client s room to provide care and find the

client lying on the floor. The nurse should first:\

• Check the client’s LOC and VS

• Which of the following actions exemplifies the use of evidence-based practice in

the delivery of client care?• Donning sterile gloves to change an abdominal wound dressing

• The registered nurse has accepted a new position as case manager in a hospital.

Which of the following responsibilities are part of the nurse s new role? Select all that apply.• Evaluating and updating the plan of care as needed • Assessing the client’s needs for home supplies and equipment • Coordinating consultations and referrals to facilitate discharge • Establishing a safe and cost-effective plan of care with the client

• The nurse manager of a quality improvement program asks a nurse in the

neurological unit to conduct a retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type of audit?\ • Obtaining the assigned medical record from the hospital’s medical room to review documentation made during a client’s hospital stay

• A nurse preparing a client for a bronchoscopy notes that the client is wearing a

gold necklace. What should the nurse do to safeguard the client s necklace?• Ask the client for permission to lock the necklace in the hospital safe

• A nurse providing preoperative care to a client who is scheduled for a left

mastectomy and axillary lymph node dissection notes that the client is wearing a

wedding band on her left ring finger. The nurse should:

• Explain to the client why the wedding band must be removed

• A nurse preparing a client to go to the radiology department for a chest x-ray

notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take?• Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms

• A physician writes a medication prescription in a client s record. While

transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the physician, who states that this is the dose that the client takes at home and that it is acceptable for this client s condition. What is the appropriate action for the nurse to take?• Contacting the nursing supervisor

• A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid

in the water seal chamber. After further assessment, the nurse suspects that the client s lung has reexpanded and notifies the physician. The physician verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest

tube be removed. The nurse should first:

• Inform the physician that removal of a chest tube is not a nursing procedure

• A nurse calls a physician to report that a client with congestive heart failure

(CHF) is exhibiting dyspnea and worsening of wheezing. The physician, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration.What is the appropriate action on the part of the nurse?• Calling the physician who gave the telephone prescription to clarify the prescription

• A nurse is assisting a physician in assessing a hospitalized client. During the

assessment, the physician is paged to report to the recovery room. The physician leaves the client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation?• Asking the physician to write the prescription in the client's record before leaving the nursing unit

• A client scheduled for surgery tells the nurse that he signed an informed consent

for the surgical procedure but was never told about the risks of the surgery. The nurse

serves as the client’s advocate by:

• Calling the surgeon and asking that the risks be explained to the client

• A nurse is planning to administer an oral antibiotic to a client with a

communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, “The medication is

needed to prevent the spread of infection, and if you don’t take it orally I will have to give it to you in an intramuscular injection.” Which of the following statements accurately describes the nurse’s response to the client?• The nurse could be charged with assault.

• A nurse discovers that another nurse has administered an enema to a client even

though the client told the nurse that he did not want one. The most appropriate action

for the nurse is to:

• Report the incident to the nursing supervisor

• A nurse calls a physician to question a prescription written for a higher-than-

normal dosage of morphine sulfate. The physician changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency s guidelines in the client s record. Which other statement does the nurse document in the nursing notes?• The physician was called to clarify the prescription for morphine sulfate.

• A charge nurse on the 11 pm–to–7 am shift is gathering the nursing staff together

to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and

suspects alcohol intoxication. The charge nurse would most appropriately:

• Send the staff member home

• A client asks a nurse about the procedure for becoming an organ donor. The

nurse tells the client:

• That anatomical gifts must be made in writing and signed by the client

• A nurse enters a client’s room to administer a medication that has been

prescribed by the physician. The client asks the nurse about the medication. Which response by the nurse is appropriate?• "It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

• A nursing student is assigned to care for a client who requires a total bed bath.

When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse in charge. Which action by the nurse in charge is appropriate?• Telling the nursing student to allow the client to rest

• A client with cancer is transported to the radiology department for a bone scan to

determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?• She will have to discuss the prescribed test with the client.

• A married couple is attending a hospital program about in vitro fertilization.

During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting

the program should:

• Explain to the television crew that videotaping is not allowed

• A nurse is taking a morning break with the unit secretary in the nurses’ lounge.

The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary?• "We can't discuss a client's medical condition."

• A nurse on the night shift is making client rounds. When the nurse checks a client

who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the

nurse should:

• Administer cardiopulmonary resuscitation (CPR)

• A physician informs a nurse that the husband of an unconscious client with

terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The physician tells the nurse to perform a slow code and let the client rest in peace if she stops breathing. How should the nurse respond?• Telling the physician that "slow codes" are not acceptable

• A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig s disease) is

admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that: • The DNR request should be discussed with the physician, who will write the order

• A man who is visiting his wife in a long-term care facility for people with

Alzheimer’s disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital physician that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember?• That a DNR order may be written by a client's physician

• A client admitted to the hospital has a do-not-resuscitate (DNR) order in his

medical record. The nurse understands that:

• The DNR order requires frequent review as specified by state or agency policy

• A registered nurse (RN) is planning client assignments for the day. Which of the

following clients should the RN assign to the nursing assistant?