NURS 1130 - LSUE - EXAM 1 - CH 22, 23, 24, 25, 26
QUESTIONS WITH COMPLETE SOLUTIONS
A 17-year-old patient, dying of heart failure, wants to have
organs removed for transplantation after death. Which action by
the nurse is correct? Correct Answer Instruct the patient to
talk with parents about the desire to donate organs.
In this situation, the parents would need to sign the form because
the teenager is under age 18. An individual who is at least 18
may sign the form allowing organ donation upon death. The
nurse cannot allow the patient to sign the organ donation
document because the patient is younger than age 18. The health
care provider will be notified about the patient's wishes after the
parents agree to donate the organs. The United Network for
Organ Sharing (UNOS) has a contract with the federal
government and sets policies and guidelines for the procurement
of organs.
A confused older-adult patient is wearing thick glasses and a
hearing aid. Which intervention is the priority to facilitate
communication? Correct Answer Allow time for the patient to
respond.
Allowing time for patients to respond will facilitate
communication, especially for a confused, older patient.
Focusing on tasks to be completed and limiting conversations do
not facilitate communication; in fact, they block communication.
Using gestures and other nonverbal cues is not effective for
visually impaired (thick glasses) patients or for patients who are
confused.
,A confused patient with a urinary catheter, nasogastric tube, and
intravenous line keeps touching these needed items for care. The
nurse has tried to explain to the patient that these lines should
not be touched, but the patient continues. Which is the best
action by the nurse at this time? Correct Answer Try other
approaches to prevent the patient from touching these care
items.
Restraints can be used when less restrictive interventions are not
successful. The nurse must try other approaches than just telling.
The situation states that the patient is touching the items, not
trying to pull them out. At this time, the patient's well-being is
not at risk so restraints cannot be used at this time nor does the
health care provider need to be notified. Allowing the patient to
pull out any of these items to prove the patient needs to be
restrained is not acceptable.
A female nursing student in the final term of nursing school is
overheard by a nursing faculty member telling another student
that she got to insert a nasogastric tube in the emergency
department while working as a nursing assistant. Which advice
is best for the nursing faculty member to give to the nursing
student? Correct Answer "You are not allowed to perform any
procedures other than those in your job description even with the
nurse's permission."
When nursing students work as nursing assistants or nurse's
aides when not attending classes, they should not perform tasks
that do not appear in a job description for a nurse's aide or
assistant. The nursing student should always follow the
,directions of the nurse, unless doing so violates the institution's
guidelines or job description under which the nursing student
was hired, such as inserting a nasogastric tube or giving an
intramuscular medication. The nursing student should be able to
safely complete the procedures delegated as a nursing assistant,
and reviewing those not done recently is a good idea, but it has
nothing to do with the situation. The focus of the discussion
between the nursing faculty member and the nursing student
should be on following the job description under which the
nursing student is working.
A home health nurse is preparing for an initial home visit.
Which information should be included in the patient's home care
medical record? Correct Answer Reports to third-party payers
Information in the home care medical record includes patient
assessment, referral and intake forms, interprofessional plan of
care, a list of medications, and reports to third-party payers. An
interprofessional plan of care is used rather than a nursing
process form. A step-by-step skills manual and a list of possible
procedures are not included in the record.
A home health nurse notices that a patient's preschool children
are often playing on the sidewalk and in the street unsupervised
and repeatedly takes them back to the home and talks with the
patient, but the situation continues. Which immediate action by
the nurse is mandated by law? Correct Answer Contact the
appropriate community child protection facility.
The nurse has a duty to report this situation to protect the
children. Any health care professional who does not report
, suspected child abuse or neglect may be liable for civil or
criminal legal action. Talking with both parents is not mandated
by law. There is no obligation to tell the parents that they will be
reported to authorities. There is no obligation for the nurse to
take pictures of the children.
A hospital is using a computer system that allows all health care
providers to use a protocol system to document the care they
provide. Which type of system/design will the nurse be using?
Correct Answer Critical pathway design
One design model for Nursing Clinical Information Systems
(NCIS) is the protocol or critical pathway design. This design
facilitates interdisciplinary management of information because
all health care providers use evidence-based protocols or critical
pathways to document the care they provide. The knowledge
base within a CDSS contains rules and logic statements that link
information required for clinical decisions in order to generate
tailored recommendations for individual patients, which are
presented to nurses as alerts, warnings, or other information for
consideration. The nursing process design is the most traditional
design for an NCIS. This design organizes documentation within
well-established formats such as admission and postoperative
assessments, problem lists, care plans, discharge planning
instructions, and intervention lists or notes. Computerized
provider order entry (CPOE) systems allow health care
providers to directly enter orders for patient care into the
hospital's information system.
A new nurse notes that the health care unit keeps a listing of
patient names in a closed book behind the front desk of the
QUESTIONS WITH COMPLETE SOLUTIONS
A 17-year-old patient, dying of heart failure, wants to have
organs removed for transplantation after death. Which action by
the nurse is correct? Correct Answer Instruct the patient to
talk with parents about the desire to donate organs.
In this situation, the parents would need to sign the form because
the teenager is under age 18. An individual who is at least 18
may sign the form allowing organ donation upon death. The
nurse cannot allow the patient to sign the organ donation
document because the patient is younger than age 18. The health
care provider will be notified about the patient's wishes after the
parents agree to donate the organs. The United Network for
Organ Sharing (UNOS) has a contract with the federal
government and sets policies and guidelines for the procurement
of organs.
A confused older-adult patient is wearing thick glasses and a
hearing aid. Which intervention is the priority to facilitate
communication? Correct Answer Allow time for the patient to
respond.
Allowing time for patients to respond will facilitate
communication, especially for a confused, older patient.
Focusing on tasks to be completed and limiting conversations do
not facilitate communication; in fact, they block communication.
Using gestures and other nonverbal cues is not effective for
visually impaired (thick glasses) patients or for patients who are
confused.
,A confused patient with a urinary catheter, nasogastric tube, and
intravenous line keeps touching these needed items for care. The
nurse has tried to explain to the patient that these lines should
not be touched, but the patient continues. Which is the best
action by the nurse at this time? Correct Answer Try other
approaches to prevent the patient from touching these care
items.
Restraints can be used when less restrictive interventions are not
successful. The nurse must try other approaches than just telling.
The situation states that the patient is touching the items, not
trying to pull them out. At this time, the patient's well-being is
not at risk so restraints cannot be used at this time nor does the
health care provider need to be notified. Allowing the patient to
pull out any of these items to prove the patient needs to be
restrained is not acceptable.
A female nursing student in the final term of nursing school is
overheard by a nursing faculty member telling another student
that she got to insert a nasogastric tube in the emergency
department while working as a nursing assistant. Which advice
is best for the nursing faculty member to give to the nursing
student? Correct Answer "You are not allowed to perform any
procedures other than those in your job description even with the
nurse's permission."
When nursing students work as nursing assistants or nurse's
aides when not attending classes, they should not perform tasks
that do not appear in a job description for a nurse's aide or
assistant. The nursing student should always follow the
,directions of the nurse, unless doing so violates the institution's
guidelines or job description under which the nursing student
was hired, such as inserting a nasogastric tube or giving an
intramuscular medication. The nursing student should be able to
safely complete the procedures delegated as a nursing assistant,
and reviewing those not done recently is a good idea, but it has
nothing to do with the situation. The focus of the discussion
between the nursing faculty member and the nursing student
should be on following the job description under which the
nursing student is working.
A home health nurse is preparing for an initial home visit.
Which information should be included in the patient's home care
medical record? Correct Answer Reports to third-party payers
Information in the home care medical record includes patient
assessment, referral and intake forms, interprofessional plan of
care, a list of medications, and reports to third-party payers. An
interprofessional plan of care is used rather than a nursing
process form. A step-by-step skills manual and a list of possible
procedures are not included in the record.
A home health nurse notices that a patient's preschool children
are often playing on the sidewalk and in the street unsupervised
and repeatedly takes them back to the home and talks with the
patient, but the situation continues. Which immediate action by
the nurse is mandated by law? Correct Answer Contact the
appropriate community child protection facility.
The nurse has a duty to report this situation to protect the
children. Any health care professional who does not report
, suspected child abuse or neglect may be liable for civil or
criminal legal action. Talking with both parents is not mandated
by law. There is no obligation to tell the parents that they will be
reported to authorities. There is no obligation for the nurse to
take pictures of the children.
A hospital is using a computer system that allows all health care
providers to use a protocol system to document the care they
provide. Which type of system/design will the nurse be using?
Correct Answer Critical pathway design
One design model for Nursing Clinical Information Systems
(NCIS) is the protocol or critical pathway design. This design
facilitates interdisciplinary management of information because
all health care providers use evidence-based protocols or critical
pathways to document the care they provide. The knowledge
base within a CDSS contains rules and logic statements that link
information required for clinical decisions in order to generate
tailored recommendations for individual patients, which are
presented to nurses as alerts, warnings, or other information for
consideration. The nursing process design is the most traditional
design for an NCIS. This design organizes documentation within
well-established formats such as admission and postoperative
assessments, problem lists, care plans, discharge planning
instructions, and intervention lists or notes. Computerized
provider order entry (CPOE) systems allow health care
providers to directly enter orders for patient care into the
hospital's information system.
A new nurse notes that the health care unit keeps a listing of
patient names in a closed book behind the front desk of the
