L&E TEST 4 QUESTIONS AND CORRECT
ANSWERS.
The nurse is caring for a client who was involuntarily hospitalized to a mental health unit
and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent
has not been obtained for the procedure. Based on this information, what is the nurse's best
determination in planning care?
2 The informed consent needs to be obtained from the client
A client has refused to eat more than a few spoonfuls of breakfast. The primary health care
provider has prescribed that tube feedings be initiated if the client fails to eat at least half
of a meal because the client has lost a significant amount of weight during the previous 2
months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more
than that, I'm going to have to put a tube down your throat and get a feeding in that way."
The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may
be accused of which violation?
1 Assault
The registered nurse (RN) is educating a new RN on the "law and order orientation" found
in level 2 of Kohlberg's theory of moral development. Which statement by the new RN
indicates that the teaching has been effective?
1 "An example of this is: If I skip down the hall, will the teacher be mad at me?"
The nurse hears a client calling out for help, hurries down the hallway to the client's room,
and finds the client lying on the floor. The nurse performs an assessment, assists the client
back to bed, notifies the primary health care provider of the incident, and completes an
incident report. Which statement would the nurse document on the incident report?
3 The client was found lying on the floor.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for
the day because the ICU is understaffed and needs additional nurses to care for the clients.
The nurse has never worked in the ICU. The nurse would take which best action?
, 2 Clarify with the team leader to make a safe ICU client assignment.
The nurse who works on the night shift enters the medication room and finds a coworker
with a tourniquet wrapped around the upper arm. The coworker is about to insert a
needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is
the most appropriate action by the nurse?
3 Call the nursing supervisor.
A hospitalized client tells the nurse that an instructional directive is being prepared and
that the lawyer will be bringing the document to the hospital today for witness signatures.
The client asks the nurse for assistance in obtaining a witness to the will. Which is the most
appropriate response to the client?
4 "I will call the nursing supervisor to seek assistance regarding your request."
The nurse has made an error in a narrative documentation of an assessment finding on a
client and obtains the document to correct the error. The nurse would take which actions to
correct the error? Select all that apply.
2 Draw one line through the error, initialing and dating it.
6 Document the correct information and end with the nurse's signature and title
Which identifies accurate documentation notations made by the nurse? Select all that
apply.
1 The client is resting in bed with the eyes closed.
2 Abdominal wound dressing is dry and intact without drainage.
5 The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
A nursing instructor delivers a lecture to nursing students regarding the issue of clients'
rights and asks a nursing student to identify a situation that represents an example of
invasion of client privacy. Which situation, if identified by the student, indicates an
understanding of a violation of this client right?
4 Observing care provided to the client without the client's permission
ANSWERS.
The nurse is caring for a client who was involuntarily hospitalized to a mental health unit
and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent
has not been obtained for the procedure. Based on this information, what is the nurse's best
determination in planning care?
2 The informed consent needs to be obtained from the client
A client has refused to eat more than a few spoonfuls of breakfast. The primary health care
provider has prescribed that tube feedings be initiated if the client fails to eat at least half
of a meal because the client has lost a significant amount of weight during the previous 2
months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more
than that, I'm going to have to put a tube down your throat and get a feeding in that way."
The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may
be accused of which violation?
1 Assault
The registered nurse (RN) is educating a new RN on the "law and order orientation" found
in level 2 of Kohlberg's theory of moral development. Which statement by the new RN
indicates that the teaching has been effective?
1 "An example of this is: If I skip down the hall, will the teacher be mad at me?"
The nurse hears a client calling out for help, hurries down the hallway to the client's room,
and finds the client lying on the floor. The nurse performs an assessment, assists the client
back to bed, notifies the primary health care provider of the incident, and completes an
incident report. Which statement would the nurse document on the incident report?
3 The client was found lying on the floor.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for
the day because the ICU is understaffed and needs additional nurses to care for the clients.
The nurse has never worked in the ICU. The nurse would take which best action?
, 2 Clarify with the team leader to make a safe ICU client assignment.
The nurse who works on the night shift enters the medication room and finds a coworker
with a tourniquet wrapped around the upper arm. The coworker is about to insert a
needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is
the most appropriate action by the nurse?
3 Call the nursing supervisor.
A hospitalized client tells the nurse that an instructional directive is being prepared and
that the lawyer will be bringing the document to the hospital today for witness signatures.
The client asks the nurse for assistance in obtaining a witness to the will. Which is the most
appropriate response to the client?
4 "I will call the nursing supervisor to seek assistance regarding your request."
The nurse has made an error in a narrative documentation of an assessment finding on a
client and obtains the document to correct the error. The nurse would take which actions to
correct the error? Select all that apply.
2 Draw one line through the error, initialing and dating it.
6 Document the correct information and end with the nurse's signature and title
Which identifies accurate documentation notations made by the nurse? Select all that
apply.
1 The client is resting in bed with the eyes closed.
2 Abdominal wound dressing is dry and intact without drainage.
5 The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
A nursing instructor delivers a lecture to nursing students regarding the issue of clients'
rights and asks a nursing student to identify a situation that represents an example of
invasion of client privacy. Which situation, if identified by the student, indicates an
understanding of a violation of this client right?
4 Observing care provided to the client without the client's permission
