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The nurse is preparing to sign a client's surgical consent form after the physician has explained the procedure to the client and family. As the client signs the form, she comments 'I really didn’t understand most of what the doctor said, but I have to have this procedure, so I want to sign.' Which is the appropriate nursing action?
- A. Witness the document, as the client states she wants to sign it.
- B. Notify the physician or nursing supervisor.
- C. Call the OR to cancel the procedure and reschedule at a later date.
- D. Explain the information she did not understand.
Correct Answer: B
Rationale: Notifying the physician or nursing supervisor (B) ensures informed consent, a legal and ethical requirement, by addressing the client’s lack of understanding. Witnessing without clarification (A) violates consent principles, canceling the procedure (C) is premature, and explaining as a nurse (D) may exceed the nurse’s role, as the physician should clarify procedure details.
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The nurse is discussing management styles with a colleague. Which of the following nursing leadership and management-related statements is accurate?
- A. Nurse managers possess personal accountability for not only their specific acts but also acts of delegation and supervision.
- B. Nurses and nurse managers are accountable for supervising others, except for unlicensed assistive personnel (UAP).
- C. When delegated to the appropriate person, the delegating nurse is no longer responsible for ensuring the task is performed correctly.
- D. Managing care entails micromanagement of the unit's staff.
Correct Answer: A
Rationale: Nurse managers are accountable for their actions and delegated tasks, including supervision (A), per nursing standards. UAPs are included in supervision (B), delegators remain responsible (C), and micromanagement (D) is ineffective, not a management goal.
The nurse manager has been made aware of the following staff nurse issues. The manager should initially follow up on the staff nurse who
- A. falsified documentation on a client discharged within the last 24 hours.
- B. needs assistance completing an incident report about a medication administration error on the previous shift.
- C. was thirty minutes late and tardy to their shift and is not wearing the correct gown uniform.
- D. is suspected of alcohol impairment and is precepting a newly hired nurse.
Correct Answer: D
Rationale: Suspected alcohol impairment while precepting (C) poses an immediate safety risk to clients and staff, requiring immediate immediate manager intervention. Falsified documentation (D), incident report assistance (A), and tardiness/uniform issues (B) are serious but less urgent than impairment.
The nurse has received a change-of-shift report for assigned clients. The nurse should initially followup on the client with
- A. cystic fibrosis who is coughing up a large amount of yellow mucus.
- B. cellulitis in the lower extremity reporting pain rated 6/10 on the Numerical Rating Scale.
- C. chronic obstructive pulmonary disease reporting blood-tinged sputum 4 hours after a bronchoscopy.
- D. dumping syndrome reporting blurred vision and disorientation.
Correct Answer: A
Rationale: Yellow mucus in cystic fibrosis (A) suggests a possible infection or exacerbation, requiring immediate assessment to prevent respiratory compromise. Cellulitis pain (B), post-bronchoscopy sputum (C), and dumping syndrome symptoms (D) are less urgent, though blurred vision in (D) warrants monitoring.
The nurse is observing practices in the behavioral health unit. Which of the practices should the nurse question?
- A. Opening all client's postal packages prior to giving them to the client.
- B. Reviewing the process of how a client may lodge a formal complaint.
- C. Allowing clients to communicate over the telephone in a private area.
- D. Allowing clients who are involuntarily admitted to refuse prescribed medication(s).
Correct Answer: D
Rationale: Allowing involuntarily admitted clients to refuse medications (D) should be questioned, as court-ordered treatment may require compliance. Opening packages (A) ensures safety, complaint processes (B) are standard, and private calls (C) respect privacy.
Which statements about an electronic medical record (EMR) system are true for the nurse working in a hospital? Select all that apply.
- A. Allows for efficient and centralized documentation of patient information.
- B. Enhances communication among healthcare providers by facilitating the sharing of patient data.
- C. Improves patient safety by reducing the risk of errors in medication administration and treatment plans.
- D. Supports evidence-based practice by providing access to medical research and clinical guidelines.
- E. Eliminates the need for physical storage of paper records, reducing clutter and saving space.
Correct Answer: A, B, C, D, E
Rationale: All statements are true: EMRs centralize documentation (A), enhance provider communication (B), reduce medication and treatment errors (C), support evidence-based practice with research access (D), and eliminate paper record storage (E). These features improve efficiency, safety, and care quality in hospitals.