The nurse is developing a hospital policy on guidelines for...

The nurse is developing a hospital policy on guidelines for telephone and verbal prescriptions. Which guidelines should the nurse include in the policy? Select all that apply.

A. Avoid using all abbreviations.
B. Verbal prescriptions are rarely acceptable.
C. Clarify any questions with the primary health care provider.
D. Repeat the prescribed prescriptions back to the primary health care provider.
E. Cosigning the prescription by the primary health care provider is not necessary.
F. If the prescriber is the client's primary health care provider, documentation is unnecessary.

Correct Answer: C,D

Rationale: To avoid misunderstandings, the nurse would always clarify a telephone or verbal prescription with the health care provider (HCP) if he or she had any questions about the prescription and would repeat any prescribed prescriptions back to the HCP. A telephone order (TO) or prescription involves a primary HCP stating a prescribed therapy over the phone to the nurse. TOs are frequently given at night or during an emergency and need to be given only when absolutely necessary. Likewise, a verbal order (VO) or prescription is acceptable when there is no opportunity for the HCP to write the prescription such as in an emergency situation. Additional guidelines for telephone and verbal prescriptions include the following: clearly determine the client's name, room number, and diagnosis; indicate TO or VO, including the date and time, name of the client, complete prescription, name of the HCP giving the prescription, and nurse taking the prescription; and have the HCP cosign the prescription within the time frame designated by the health care agency (usually 24 hours).

At the scene of a train crash, the nurse triages the victims. Which clients should be coded for triage as most urgent or the first priority? Select all that apply.

A. Is dead
B. Has chest pain
C. Has a leg sprain
D. Has a chest wound
E. Has multiple fractures
F. Has full-thickness burns over 30% of the body

Correct Answer: B,D,F

Rationale: In a disaster situation, saving the greatest number of lives is the most important goal. During a disaster the nurse would triage the victims to maximize the number of survivors and sort the treatable from the untreatable victims. First priority victims (most urgent and coded red) have life-threatening injuries and are experiencing hypoxia or near hypoxia. Examples of injuries in this category are shock, chest wounds, internal hemorrhage, head injuries producing loss of consciousness, partial- or full-thickness burns over 20% of the body surface, and chest pain. Second priority victims (urgent and coded yellow) have injuries with systemic effects but are not yet hypoxic or in shock and can withstand a 2-hour wait without immediate risk (e.g., a victim with multiple fractures). Third priority victims (coded green) have minimal injuries unaccompanied by systemic complications and can wait for more than 2 hours for treatment (leg sprain). Dying or dead victims have catastrophic injuries, and the dying victims would not survive under the best of circumstances (coded black).

The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?

A. Isolate the child until the skin vesicles have dried and crusted.
B. Ensure that the child uses a separate bathroom for elimination.
C. Bring all household members to the clinic for a varicella vaccine.
D. Request a prescription for antibiotics for all household members.

Correct Answer: A

Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.

The nurse caring for a chronically ill client with a poor prognosis shows an understanding of the basic values that guide the implementation of a living will by asking which questions? Select all that apply.

A. Are you planning to become an organ donor?
B. Do you feel the need to discuss your end-of-life decisions with your family?
C. Did you have the discussion with your son about being your health care surrogate?
D. Can we discuss what will happen if you decide to refuse antibiotics if you get an infection?
E. Have you given thought to whether you want cardiopulmonary resuscitation (CPR) measures if your condition worsens?

Correct Answer: B,D,E

Rationale: A living will lists the treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill. The client may want to discuss her or his decisions with the family. Although both the living will and durable powers of attorney for health care are based on values of informed consent, autonomy over end-of-life decisions, and control over the dying process, living wills do not involve health care surrogates or the decision to donate organs.

A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply.

A. Assess the client's visual acuity.
B. Observe the client's gait and posture.
C. Evaluate the client's muscle strength.
D. Look for any hazards in the home care environment.
E. Ask a family member to move in with the client until recovery is complete.
F. Request that the client transfer to an assisted living environment for at least 1 month.

Correct Answer: A,B,C,D

Rationale: To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment should include assessing visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse should also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.

The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should include which interventions as examples of the nurse acting as a client advocate? Select all that apply.

A. Obtaining an informed consent for a surgical procedure
B. Providing information necessary for a client to make informed decisions
C. Providing assistance in asserting the client's human and legal rights if the need arises
D. Including the client's religious or cultural beliefs when assisting the client in making an informed decision
E. Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being

Correct Answer: B,C,D,E

Rationale: In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. The nurse advocates for the client by providing information needed so that the client can make an informed decision. The nurse needs to consider the client's religion and culture when functioning as an advocate and when providing care. The nurse would include the client's religious or cultural beliefs in discussions about treatment plans so that an informed decision can be made. The nurse also defends clients' rights in a general by speaking out against policies or actions that might endanger the client's well-being or conflict with his or her rights. Informed consent is part of the primary health care provider-client relationship; in most situations, obtaining the client's informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent.