Nokea
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 the 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 the ct verbalized understanding."?
Correct Answer: C
Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.
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While on the wound care team, the nurse notices that a fellow nurse opens extra colloid dressings that are often thrown away when they are not needed. What should the nurse do?
- A. Do nothing, as it is not impacting client care.
- B. Discuss with the colleague the concern about wasting supplies.
- C. Tell the charge nurse to stop ordering these dressings.
- D. Remove the colloid dressings from the shelf so that the nurse will find other supplies to use.
Correct Answer: B
Rationale: The correct answer is to discuss with the colleague the concern about wasting supplies. By addressing this issue, the nurse can promote cost-effective care within the unit. While it may not directly impact client care, the wastage of supplies affects the unit's supply cost, making choice A incorrect. Choice C is incorrect as it assumes the charge nurse is solely responsible for the ordering process and overlooks the opportunity for direct communication between colleagues. Choice D is incorrect as it involves taking matters into one's own hands rather than addressing the issue through communication and collaboration.
A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a 'slow code' and let the client 'rest in peace' if she stops breathing. How should the nurse respond?
- A. Telling the health care provider that the client would probably want to die in peace
- B. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken
- C. Telling the health care provider that all of the nurses on the unit agree with this plan
- D. Telling the health care provider that 'slow codes' are not acceptable
Correct Answer: D
Rationale: The nurse may not violate a family's request regarding the client's treatment plan. A 'slow code' is not acceptable, and the nurse should state this to the health care provider. The definition of a 'slow code' varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are inappropriate: Option A is speculative and does not address the issue directly; Option B does not challenge the unethical practice of a 'slow code'; Option C is irrelevant and does not address the ethical concerns raised by the health care provider's request.
An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?
- A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- B. The client will maintain a blood glucose level within normal range limits today.
- C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct Answer: C
Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.
The client is unsure about making medical decisions as their disease progresses and wants to appoint someone 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: The correct answer is 'a healthcare proxy.' A healthcare proxy involves the client appointing an individual to make medical decisions on their behalf if they become unable to do so. This option allows the client to choose someone they trust to act in their best interests.
Choice A, 'a living will,' is a legal document that outlines a person's wishes regarding medical treatment in case they are unable to communicate their decisions. While it is important, it does not involve appointing someone to make decisions.
Choice B, 'informed consent,' is a process where a healthcare provider explains a treatment or procedure, including its risks and benefits, to a patient who can then decide whether to proceed. This is not about appointing someone to make decisions on the patient's behalf.
Choice D, 'non-informed consent,' is not a valid concept in healthcare. Informed consent is crucial for respecting a patient's autonomy and decision-making capacity.
Which is the correct order regarding the hierarchy of members of the nursing team from least authority to highest authority?
- A. LPN, staff nurse, charge nurse, nurse manager
- B. Staff nurse, LPN, nurse manager, charge nurse
- C. LPN, staff nurse, charge nurse, nurse manager
- D. LPN, staff nurse, charge nurse, nurse manager
Correct Answer: C
Rationale: The correct hierarchy order from least to highest authority in the nursing team is LPN (Licensed Practical Nurse), staff nurse, charge nurse, and nurse manager. LPNs have the least authority, followed by staff nurses who are supervised by charge nurses. Nurse managers oversee the charge nurses, making them the highest authority in this hierarchy. Therefore, choices A, B, and D are incorrect as they do not follow the correct order of authority within the nursing team.