Nokea
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?
- A. Yes, he does, but be sure not to discuss this with anyone else.
- B. Yes, that's why we've imposed contact precautions.
- C. We can't discuss a client's medical condition.
- D. Oh, really? I didn't see that!
Correct Answer: C
Rationale: A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's healthcare provider. Therefore, the nurse must tell the unit secretary that the client's condition is not to be discussed. Choices A and B confirm the client's disease, which is inappropriate as it breaches patient confidentiality. Choice D promotes further discussion of the client's condition, which is also inappropriate. The correct response is to firmly state, 'We can't discuss a client's medical condition,' to uphold patient privacy and confidentiality.
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Which of the following activities is not part of client advocacy?
- A. involving the client in treatment and decision-making
- B. standing up for what is right for the client
- C. sharing your personal opinions to help provide additional information
- D. encouraging the client to advocate for themselves
Correct Answer: C
Rationale: The correct answer is 'sharing your personal opinions to help provide additional information.' Client advocacy involves supporting the client's autonomy and choices. It is essential for the nurse to involve the client in treatment and decision-making (Choice A) to ensure their preferences are considered. Standing up for what is right for the client (Choice B) is also a crucial aspect of advocacy, ensuring their rights and well-being are protected. Encouraging the client to advocate for themselves (Choice D) empowers the client to express their needs. However, sharing personal opinions (Choice C) may influence the client's decision-making process and is not a recommended practice in client advocacy, as it can compromise the client's autonomy.
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 take which action?
- A. Administer cardiopulmonary resuscitation (CPR)
- B. Call the client's health care provider
- C. Administer oxygen to the client and call the health care provider
- D. Contact the nursing supervisor for directions
Correct Answer: A
Rationale: Administering cardiopulmonary resuscitation (CPR) is the appropriate action when a client is not breathing and does not have a do-not-resuscitate (DNR) order. CPR is considered an emergency treatment that can be provided without client consent in life-threatening situations. Calling the health care provider or nursing supervisor for directions, as well as administering oxygen without addressing the lack of breathing, would delay critical life-saving interventions. Therefore, administering CPR is the most urgent and necessary action to perform in this scenario.
A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?
- A. 'I know that it's for fluid buildup, and I think you've taken it before.''
- B. '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.''
- C. 'It's to help get rid of the swelling in your feet.''
- D. ''You need to discuss this medication with your health care provider.''
Correct Answer: B
Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.
A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
- A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
- B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
- C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
- D. Negligence, as the nurse ignored the client's right to choose regarding his healthcare.
Correct Answer: A
Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation.
The other options are incorrect:
- Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions.
- Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving.
- Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.
An LPN on a Continuous Quality Improvement (CQI) team is tasked with implementing strategies to reduce medication errors. Which of the following strategies would be most beneficial for the LPN to implement?
- A. Track individuals who commit medication errors and report them to administration.
- B. Remind staff of the five rights of medication administration.
- C. Ensure that all staff members are proficient in completing incident reports if a medication error occurs.
- D. Double-check that staff document medication administration in the electronic medical record.
Correct Answer: C
Rationale: The most beneficial strategy for the LPN on a CQI team to implement is to ensure that all staff members are proficient in completing incident reports if a medication error occurs. Organized and accurate incident reports are crucial in tracking and understanding why errors occurred. CQI teams utilize incident reports to develop new policies or enhance existing ones to standardize medical processes and reduce errors. Tracking individuals with medication errors (Choice A) may create a culture of blame rather than focusing on system improvements. Reminding staff of the five rights of medication administration (Choice B) is important for knowledge reinforcement but does not directly address the process improvement aspect. Double-checking documentation in the electronic medical record (Choice D) is necessary for accuracy but does not provide the detailed insights obtained from incident reports for process improvement.