Nokea
An example of a process standard on a med-surg unit is:
- A. a procedure for changing IV tubing.
- B. a policy for staffing.
- C. the job description of the CEO (chief executive officer).
- D. a procedure for checking waveforms on a client being treated on an intra-aortic balloon pump.
Correct Answer: A
Rationale: Process standards define the actions and behaviors required by staff to provide care.
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The nurse is caring for a client who is unsure they will be able to make medical decisions as their disease progresses and would like to appoint another individual to have the authority to make these decisions. Which of the following options would be most appropriate?
- A. a living will
- B. informed consent
- C. a healthcare proxy
- D. non-informed consent
Correct Answer: C
Rationale: A healthcare proxy involves the client appointing an individual to make medical decisions with regard to their treatment if they are unable to do so themselves.
Which of these would be the most appropriate way to document a client's refusal of medication?
- A. Heparin refused during shift. Risks reviewed.'
- B. The client refused the heparin injection when I tried to administer it. She yelled at me saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift.'
- C. Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client and client verbalized understanding.'
- D. Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct and ct verbalized understanding.'
Correct Answer: C
Rationale: Documentation in healthcare should be objective, thorough, but direct. It should be articulate, with correct grammar and spelling.
A concern regarding maternal and infant mortality and morbidity is that:
- A. a segment of the population is not receiving prenatal care.
- B. families appear unconcerned about quality health care.
- C. the personnel shortage in the maternity field will increase.
- D. maternal-child health workers are not adequately prepared.
Correct Answer: A
Rationale: There is a concern that a segment of the population is not accessing prenatal care, affecting infant and maternal mortality and morbidity.
While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. The nurse should:
- A. make the charge nurse on the unit aware of the situation so that he or she can take the necessary steps to maintain the confidentiality of the information being reported.
- B. disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
- C. return to his or her own unit and not disclose that confidential information has been overheard.
- D. ignore the situation.
Correct Answer: A
Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation so that the information can be communicated in an appropriate way in privacy.
Delegation of tasks to appropriate personnel allows the nurse to:
- A. take a break.
- B. keep other members of the team productive.
- C. maintain tight control of all aspects of the workflow.
- D. realize the importance of her role by making all decisions.
Correct Answer: B
Rationale: Maintaining the productivity of all team members by delegating tasks appropriate to the job descriptions of the personnel increases work effectiveness and efficiency.