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The LPN administered a medication to a client reporting pain. When checking the armband and the medication administration record, there were no allergies listed. The client then tells the nurse of having informed the admitting nurse of being allergic to that medication. What documentation on the incident form would be the best option?
- A. Medication is administered to client by mouth; reports having an allergy to the medication that causes hives.'
- B. The admitting nurse failed to document that the client has an allergy to the medication.'
- C. The client reports being allergic to the medication, but I really don't think so. I didn't see any hives.'
- D. I should have asked the RN if the client is allergic to any medication.'
Correct Answer: A
Rationale: Healthcare workers complete incident reports when they make or discover errors or when an event occurs that results in harm. The first option is concise and to the point without any accusation. The LPN's documentation should not accuse the admitting nurse of failure to document. The LPN's documentation should not judge the client's statement nor place blame on the client. The LPN's documentation also should not place the blame on oneself.
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The nurse is preparing a client for a colonoscopy at the hospital. Who does the nurse understand is responsible for obtaining the informed consent from this client?
- A. The nurse
- B. The primary provider
- C. The nurse manager
- D. The health care provider's office nurse
Correct Answer: B
Rationale: The primary provider obtains the informed consent and must inform the client of the description of the procedure, potential benefits, material risk involved, acceptable alternatives available, expected outcome, and consequences if the procedure is not done.
A client who has end-stage chronic obstructive pulmonary disease (COPD) asks the nurse, 'Am I going to be getting better? Is there a cure?' What is the best response by the nurse that demonstrates the professional value, veracity?
- A. Everything will be fine.'
- B. Did someone tell you that there is a cure for this?'
- C. You don't need to worry about that; just get better.'
- D. Although there is no cure for this disease, we will keep you as comfortable as possible.'
Correct Answer: D
Rationale: The professional value of veracity is the duty to tell the truth. The nurse must provide factual information so the client may exercise autonomy. 'Everything will be fine,' 'Did someone tell you that there is a cure for this?', and 'You don't need to worry about that; just get better' are nontherapeutic responses that do not answer the client's question.
The nurse is administering a medication to a client for the treatment of constipation. The client expresses preferring not to take the medication today. The nurse respects the client's right and says if the client needs it later, just let the nurse know. What professional value is the nurse displaying?
- A. Beneficence
- B. Nonmaleficence
- C. Autonomy
- D. Fidelity
Correct Answer: C
Rationale: Autonomy refers to a client's right to self-determination or the freedom to make choices without opposition. Nonmaleficence is the duty to do no harm to the client. If a nurse fails to check a prescription for an unusually high dose of insulin and administers it, the nurse has violated the principle of nonmaleficence. Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints whenever possible (removing a harm) and to help the client regain independence (promoting and doing good). Fidelity is the duty to maintain commitments of professional obligations and responsibilities.
The nurse is assigned to care for a client who is admitted to the medical unit with an infection after having an abortion. The nurse is uncomfortable caring for this client because the religious beliefs of the nurse are very firm on the issue of abortion. What first step can the nurse make in order to solve the ethical dilemma?
- A. Evaluate the decision in terms of effects and results.
- B. Make the decision and follow through on it.
- C. List all possible options for solving the dilemma.
- D. Obtain as much information as possible to understand the situation.
Correct Answer: D
Rationale: The first step in the ethical dilemma decision-making process is to obtain as much information as possible to understand the situation. Evaluating the decision in terms of effects and results is the fifth step in the process. Making the decision and following through is the fourth step of the process, and listing all possible options is the second step in the process.
The nurse is caring for a terminally ill client in the intensive care unit that is on life support measures. The family members are opposed in their decision to take the client off of life support. What option does the nurse discuss with the nurse manager?
- A. Ask the family to go out of the unit and make a decision that is final.
- B. Contact the ethics committee for their input.
- C. Have the health care provider inform the family that they are not responsible for the decision.
- D. Take the client off of life support when the family is not present.
Correct Answer: B
Rationale: The ethics committee may be called on to act as an advocate for clients who no longer are mentally capable of making their own decisions. Ethics committees are a valuable resource for reviewing difficult cases and helping ensure a careful and unbiased decision. The nurse is not practicing within the scope of practice by taking the client off of life support. The nurse does not mandate to the health care provider decisions that should be made. It is nontherapeutic for the nurse to ask the family to go out and make a decision.