Elizabeth Hutchins - Unit II Chapter 7 Issues in Nursing: Ethical an...

Elizabeth Hutchins ATI Leadership Retake NCLEX Assignment

Unit II Chapter 7

Issues in Nursing: Ethical and Legal Issues (pp. 60)

• The nurse hears a client calling out for help, hurries down the hallway to the client’s

room, and finds the client lying of the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

My Answer: 3 - The client was found lying in the floor

Correct Answer: 3

• A client is brought to the emergency department by emergency medical services (EMS)

after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

My Answer: 3 - Transport the victim to the operating room for surgery

Correct Answer: 3

15 The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?

My Answer: 4 - Contact the nursing supervisor to update information regarding

the call

Correct Answer: 1 - Reassess the client

Rationale: After a client’s fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall.

16 The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first?

My Answer: 4 - Identify tasks that can be performed safely in the ICU

Correct Answer: 4

• The nurse who works on the night shift enters the medication room and finds a co-worker

which a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

My Answer: 3 - Call the nursing supervisor

Correct Answer: 3

Elizabeth Hutchins ATI Leadership Retake NCLEX Assignment

• A hospitalized client tells the nurse that a living will is being prepared and that the lawyer

will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

My Answer: 4 - I will call the nursing supervisor to seek assistance regarding

your request

Correct Answer: 4

• The nurse has made an error in a narrative documentation of an assessment finding on a

client and obtains the client’s medical record to correct the error. The nurse should take which action to correct the error?

My Answer: 4 - Drawing one line through the error, initialing and dating, and

then documenting the correct information

Correct Answer: 4

• Which identifies accurate nursing documentations notations?

My Answers: 2, 5

• Abdominal wound dressing is dry and intact without drainage
• The client’s left lower medial leg wound is 3cm in length without

redness, drainage, or edema

Correct Answers: 1, 2, 5

• The client slept through the night
• Abdominal wound dressing is dry and intact without drainage
• The client’s left lower medial leg wound is 3cm in length without

redness, drainage, or edema

Rationale: Factual documentation contains descriptive, objective information

about what the nurse sees, hears feels, or smells.

• A nursing instructor delivers a lecture to nursing students regarding the issue of client’s

rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student indicates an understanding of a violation of this client right?

My Answer: 4 - Observing care provided to the client without the client’s

permission

Correct Answer: 4

• Nursing staff members are sitting in the lounge taking their morning break. An

unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nurse staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated?

My Answer: 2 - Slander

Correct Answer: 2

Elizabeth Hutchins ATI Leadership Retake NCLEX Assignment

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper if not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

My Answer: 4 - As a nurse, I am legally bound to report abuse. I will stay with

you while you give the report and help find a safe place for you to stay

Correct Answer: 4

• The nurse calls the health care provider (HCP) regarding a new medication prescription

because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered, Which action should the nurse take?

My Answer: 3 - Hold the medication until the HCP can be contacted

Correct Answer: 1 - Contact the nursing supervisor

Rationale: If the HCP writes a prescription that requires clarification, the nurse’s responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be.

• The nurse employed in a hospital is waiting to receive a report from the laboratory bin the

facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photography. Which is the most appropriate nursing action?

My Answer: 3 - Call the nursing supervisor and report the incident

Correct Answer: 3

Unit II Chapter 8 Prioritizing Client Care: Leadership, Delegation & Disaster Planning (pp .77)

• The nurse is assigned to care for four clients. In planning client rounds, which client

should the nurse assess first?

My Answer: 4 - A client receiving nasal oxygen who had difficulty breathing

during the previous shift

Correct Answer: 4

Elizabeth Hutchins ATI Leadership Retake NCLEX Assignment

• The nurse employed in an emergency department is assigned to triage clients coming to

the emergency department for treatment on the evening shift. The nurse should assign priority to which client?My Answer: 4 - A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

Correct Answer: 4

• A nursing graduate is attending an agency orientation regarding the nursing model of

practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning acre delivery will be based on which characteristic of this type of nursing model of practice?

My Answer: 1 - A task approach method is used to provide care to clients

Correct Answer: 4 - A registered nurse leads nursing personnel in providing care to group of clients Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients.

• A nurse has received the assignment for the day shift. After making initial rounds and

checking all of the assigned clients, which client should the nurse plan to care for first?

My Answer: 3 - A client with a fever who is diaphoretic and restless

Correct Answer: 3

• The nurse is giving a bed bath to an assigned client when an unlicensed assistive

personnel (UAP) enters the client’s room and tells the nurse that another assigned client Is in pain and needs pain medication. Which is the most appropriate nursing action?

My Answer: 3 - Ask the UAP to tell the client in pain that medication will be

administered as soon as the bed bath is complete Correct Answer: 4 – Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation Is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication.

• The nurse manager has implemented a change in the method of the nursing delivery

system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the bests approach in dealing with the UAP?

My Answer: 4 - Confront the UAP to encourage verbalization of feelings

regarding the change

Correct Answer: 4

• The registered nurse is planning the client assignments for the day. Which is the most

appropriate assignment for an unlicensed assistive personnel (UAP)?