McGraw-Hill Review for the NCLEX-RN Examination

QUESTIONS Do you have key facts from this chapter on your NCLEX-RN® knowledge ring? Complete the worksheet below to help you check. 1. Why is passing the NCLEX-RN® a requirement for being licensed as a registered nurse? 2. At what level of practice is the NCLEX-RN® designed to measure competence? 3. What are the two major considerations in the selection of content to be tested on the NCLEX-RN®? 4. Who are the writers of NCLEX-RN® test questions? 5. What is the predominant type of question found on the NCLEX-RN®? 6. How many questions does one have to get right in order to pass the NCLEX-RN®? 7. What is the maximum length of time that one can take to complete the NCLEX-RN®? 8. Do you need to be proficient in use of a computer in order to do well on NCLEX-RN®? 9. Can you skip a question on NCLEX-RN® and go back to it if you are not sure of the answer? 10. Does having the test stop when only 75 questions have been answered mean that you have failed? 8 PART I: Testing Smart ANSWERS & RATIONALES WORKSHEET ANSWERS 1. Why is passing the NCLEX-RN® a requirement for being licensed as a registered nurse? Answer To protect the safety of the public by limiting the practice of Registered Nursing to those individuals who have passed an examination, which documents ability to practice competently, knowledgeably, and safely. 2. At what level of practice is the NCLEX-RN® designed to measure competence? Answer Entry-level Registered Nurse Practice. 3. What are the two major considerations in the selection of content to be tested on the NCLEX-RN®? Answer Frequency with which the information is needed in day-to-day practice and the criticality of the information to the patient. 4. Who are the writers of NCLEX-RN® test questions? Answer Registered nurses who work with new graduates in their practice. 5. What is the predominant type of question found on the NCLEX-RN®? Answer Multiple-choice question. 6. How many questions does one have to get right in order to pass the NCLEX-RN®? Answer It varies because NCLEX-RN® is a computer adaptive test and the decision on whether a test taker passes or fails is based on the difficulty of the questions answered and not on the absolute number. 7. What is the maximum length of time that one can take to complete the NCLEX-RN®? Answer 6 hours. 8. Do you need to be proficient in use of a computer in order to do well on NCLEX-RN®? Answer No, studies have shown that computer proficiency has no effect on passing or failing. 9. Can you skip a question on NCLEX-RN® and go back to it if you are not sure of the answer? Answer No, a question cannot be skipped and once a question has been answered and the ENTER key has been hit the sec- ond time to register the answer, one cannot go back to the question. 10. Does having the test stop when only 75 questions have been answered mean that you have failed? Answer When the test stops after the minimum of 75 questions have been answered can mean one either passed or failed. The pass/fail decision is based on the difficulty of the questions answered correctly or incorrectly, not on the number. Test and Language Basics To answer an examination question correctly, knowing the subject content is not enough. You have to clearly under- stand each part of the question in the context of nursing and correctly interpret the meaning of the question itself. Because nursing is a practice profession and the NCLEX- RN is measuring basic practice competencies, questions typically contain a clinical scenario followed by the ques- tion stem. In the case of multiple-choice questions, options follow. When taking an examination, it is important for you to recognize each of these question parts, so read the following definitions and look at the example carefully. • Clinical scenario: This part of the question tells you about the clinical situation. • Stem: This part of the question contains the actual prob- lem/question to be answered. • Options: These are the answer choices provided. Options are also called alternatives and in the case of traditional multiple-choice questions, consist of one correct answer (the key) and three distracters or incorrect answers. It is important that you read and understand each of these parts correctly for a lot of reasons. • Facts provided in the scenario are often critical to select- ing the best answer to the question. If these facts are not correctly understood, it is difficult to select the best answer. • If the question being asked is not correctly understood, distracters, which sometimes answer a different question than the one asked in the stem or assume information not provided in the stem or in the scenario, are more likely to be perceived as the correct answer. • Most questions also contain key words. These are words that direct the answer; hence, attention to them along with clear understanding of their meaning is essential. KEY WORDS Because key words are so important in determining the cor- rect answer to a question, a list of frequently used key words is presented below for your review. Note that some of the words are negative. First Priority Next Best Most Least Appropriate Inappropriate Last Suitable Not Early Late Immediately Initial Only After Every Expected Contraindicated Partial Unexpected Independently Common Uncommon The following question illustrates the use and impor- tance of a key word: When giving medications to a client, what should the nurse do first? 1. Position the client 2. Check the client’s identity 3. Explain what he/she is going to do 4. Ask how the client is feeling In this example, all options are correct nursing actions when giving medications but which one is the correct Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use. 9 CHAPTER 2 10 PART I: Testing Smart answer is determined by the qualifying word “first.” The first action is to check the client’s identity. Practice identifying key words by completing the following exercise: WORKSHEET 1: IDENTIFICATION OF KEY WORDS Directions: Read each of the following questions. If the question contains a key word, underline it. 1. Which clinical manifestation would the nurse expect when assessing a client admitted with a diagnosis of bacterial pneumonia? 2. Which sign should alert the nurse to a potential problem in a client with a history of a CVA? 3. What is the primary goal for the hospice care of a client with lung cancer? 4. Which nursing intervention should be given priority in the plan of care for a teenager with sickle cell anemia? 5. The nurse is assessing the nutritional status of a client who is 3 months pregnant. Which information is most important for the nurse to obtain? 6. The nurse is obtaining a health history of a debili- tated client with sacral pressure ulcers. Which ques- tion should the nurse ask to elicit information effec- tively about the client’s dietary intake? 7. Which behavior by a client with a newly created colostomy should alert the nurse to the need for teaching regarding skin care? 8. What is the best way to assess for shortness of breath in a 3-year-old client with congenital heart disease? 9. The nurse is assessing a family’s ability to provide emotional support to a family member diagnosed with cancer. Which observation is most essential? 10. In analyzing a teenage primipara’s need for teaching, the clinic nurse should ask which question? 11. Which finding should the nurse expect when check- ing urinary output of a client with SIADH? 12. Which information would be most helpful when preparing to do a home assessment prior to discharge of a low birth weight newborn? 13. Why is it important to monitor pulse rate in a client on digoxin? 14. A 25-year-old woman comes to the clinic com- plaining of lower left abdominal pain. Which additional information should the nurse obtain initially? 15. Which assessment question should receive priority? FREQUENTLY MISUNDERSTOOD/MISREAD ENGLISH WORDS Almost everyone has one or more words that he/she somehow learned incorrectly and as a result misunderstands its precise meaning. These can be very common, simple words and often the person is unaware of the error. This can be a particular problem when English is a person’s second language, or is not the language of the household. Words that are similar in spelling and in pronunciation are particularly at risk of being misread, misused, or misunderstood. Because errors of this type can cause an NCLEX-RN question to be answered incor- rectly, a list of potentially misleading, common English words follows. Each word is followed by its definition and a sentence illustrating its use in nursing practice. You should read each one carefully and ask yourself if you were clear about the use of the word and its meaning. If your answer is Yes—great! If the answer is No, mark the word to be reviewed again. Accept—to agree or receive. Examples: The client accepted the diagnosis of breast cancer with surprising calm. The client accepted the nurse’s recommendation that all his drugs be ordered at the same pharmacy. Except—indicates something is to be omitted or left out. Example: All the assessment findings except the rash are consistent with a lower respiratory infection. Advice—suggestion, guidance, or counsel. Example: The client asked the nurse for advice on the best way to apply the ileostomy bag. Advise—to give a suggestion, guidance, or counsel. Example: The nurse advised the new mother to nap in the afternoon when the baby is sleeping. Assent—to agree to. Example: The nurse assented to a change in unit assign- ment for the day. Ascent—to rise or to climb. Example: The ascent of carbon monoxide levels in an enclosed area when a car is left running is rapid and can result in fatality. Breath—air pulled into the lungs in one inhalation. Example: Take a deep breath and hold it while I listen with the stethoscope over your lungs. Breathe—the act of inhaling and exhaling air from the lungs. Example: Breathe in slowly and deeply through your mouth. Caster—wheel on a swivel. Example: Many pieces of hospital equipment such as IV pumps and over-the-bed tables are on casters for ease of transport. Castor—oil from castor beans, used as a laxative. Example: A single dose of castor oil was ordered as part of the prep for the client’s upcoming bowel surgery. Charted (Not chartered)—entered in the client record. Example: The nurse charted the appearance of the wound in the client’s record. Sight (Not site or cite)—vision. Example: Eyesight typically declines with age. Site (not cite)—location. Example: The planned donor site for the skin graft was the left, upper, outer thigh. Coarse (not course)—rough, uneven. Example: The skin of clients with hypofunction of the thyroid is often coarse in texture. Course—progression, order, direction. Example: The course of the disease is characterized by exacerbations and remissions. Compliment—praise. Example: The supervisor complimented the nurse on her efficient handling of the multiple emergency admis- sions, which occurred during her shift. Complement—add to or mix well. Example: Participation in a support group can comple- ment individual counseling. Complaint—expression of something wrong. Example: The client’s chief complaint was a sharp pain in the left chest. Compliant—willing to follow requirements or directions. Example: The client verbalized a desire to be compliant with the medication regimen but stated he could not be because he could not afford to buy the medications ordered. Continuous—going on without stopping. Example: The client was receiving continuous feedings via a nasogastric tube. Continually—happening at regular intervals or again and again. Example: The client continually complained of nausea while receiving the antibiotic. CHAPTER 2 Test and Language Basics 11 Defective—faulty or abnormal. Example: The neonate was diagnosed with a defective mitral valve. Deficient—lack of. Example: Genetic syndromes characterized by deficient chromosomal material are more often fatal than those characterized by excess chromosomal material. Dessert (not desert)—sweet foods served at the end of a meal. Example: The nurse advised the client to eliminate desserts as a step in controlling weight. Uninterested (not disinterested)—not caring. Example: The client appeared markedly uninterested in learning about the prescribed diet. Elicit—draw out information. Example: The nurse’s questions while obtaining the client history are designed to elicit complete, accurate information on which to base a nursing diagnosis. Illicit—illegal. Example: When obtaining a history, questions should be asked about the use of prescription drugs, over-the- counter drugs, herbal preparations, nutritional supple- ments, and illicit drugs. Imminent (not Eminent)—about to happen. Example: An aura, unique to the individual, is often the sign of an imminent seizure. Farther—greater distance. Example: The client should be ambulating farther than the bathroom. Further—more. Example: Before discharging the client, the physician decided further discussion with the family concerning plans for home care was necessary. Former—the first of two. (Latter refers to the second of two.) Example: Nausea and vomiting are common side effects to some medications.The former is a symptom because it cannot be seen, felt, or heard by an external observer; the latter is a sign because it can be observed. Healthy—not ill, well. Example: The child appeared healthy. Healthful—promoting wellness. Example: Adequate daily intake of calcium is healthful. Lose—misplace, be deprived of. Example: Clients lose central vision with macular degeneration; they lose peripheral vision with glau- coma. 12 PART I: Testing Smart Loose—opposite of tight. Example: Loose bowel movements can be a problem for clients following an intestinal resection. Nauseous—inducing a feeling of nausea. Example: The nauseous smell of the drainage made the dressing difficult to change. Nauseated—experiencing nausea. Example: The client became nauseated 2 hours after the chemotherapy was administered. Past—time gone by, ago. Example: The time is past that medications could have helped; now surgery is the only option. Passed—moved along, went away, departed, succeeded on a test. Examples: The suppository passed the rectal sphincter without dif- ficulty. The client passed a renal calculus last evening. Patient—recipient of care. Example: The patient thanked the nurse for making her comfortable. Patience—tolerance or understanding. Example: Patience is often needed when dealing with sick children. Peace—calmness, tranquility. Example: Helping the client achieve peace of mind is a goal of the hospice nurse. Piece—part or section. Example: The piece of the Foley catheter that inflates to hold the catheter in the urinary bladder is called the balloon. Personal—private. Example: Use of personal information about clients is governed by the HIPAA regulations. Personnel—employees. Example: Nurses are licensed health care personnel. Prescribe—order for. Example: The nurse practitioner prescribed the antibiotic Cipro for the client with a urinary tract infection. Proscribe—prohibit. Example: Leaving the unit with the narcotics key is pro- scribed. Principal—of major importance. Example: A principal use of digitalis is to strengthen the contraction of the myocardium in cases of heart failure. Principle—a truth. Example: The principle underlying use of a fan for cool- ing is that one of the ways heat is lost from the body is by convection. Proceed—go on, continue. Example: The nurse proceeded with the dressing change after the client had stopped coughing. Precede—go before. Example: Mild signs of an upper respiratory infection preceded the development of the rash. Quite—a great deal. Example: The client was quite verbal regarding his opinion of his care. Quit—leave or stop. Example: The client stated he wished he could quit smoking. Rise—get oneself up. Example: The client who had a CVA said to the nurse “I look forward to the day I can rise out of the bed in the morning without assistance.” Raise—lift or elevate an object or person. Example: During a breast examination, the client needs to raise her arms over her head so the contours of the breast can be inspected. Stationary—not moving. Example: The brake on the wheelchair should be set when the client is being moved in or out of the chair in order to keep the chair stationary and help prevent the client from falling. Stationery—paper. Example: Official letters should be written on stationery imprinted with the agency letterhead. Statute—legal restriction. Example: The statute of limitation for malpractice cases differs state to state. Stature—person’s size. Example: The client’s stature was consistent with a diag- nosis of hypopituitary dwarfism. Adequate—sufficient. Example: It is the nurse’s responsibility to determine if the client’s 24-hour fluid intake and output is adequate. Aggravate—make worse. Example: Straining at stool will aggravate hemor- rhoids. Allay—put at rest or cause to subside. Example: Providing the client with information about a procedure to be done can allay anxiety. Anticipate—take up or use ahead of time. Example: Prior to entering an isolation room, it is impor- tant that the nurse anticipate client needs so that she is prepared with knowledge and equipment to provide the needed care.” Avoid—keep away from. Example: Immunosuppressed clients need to avoid crowds because of the risk of exposure to infection. Competitive—contest between rivals. Example: In competitive inhibition of enzyme activity, the inhibitor competes with the substrate for binding on the enzyme. Compromised—to endanger. Example: Circulation to the lower extremities is com- promised when the client is in lithotomy position. Assume—take for granted. Example: The nurse should never assume the client has understood instructions; validation of understanding by repeating the instructions or by return demonstration is always necessary. At least—the very minimum. Example: If the client refuses to lie in the prone posi- tion, at least have him lie on his side.” Confer—consult or to bestow. Example: The Client Care team conferred to determine the best approach to manage the bladder retraining pro- gram of a newly admitted client. Deny—declare not to be true. Example: Clients sometimes deny use of illegal drugs because they fear the reaction of the health care provider. Determine—to come to a decision or to obtain first hand knowledge. Example: To determine the causative organism of a wound infection, a culture is done. Differentiate—discriminate or identify differences. Example: When examining the chest, it is important to differentiate between crackles and wheezes. Exacerbate—worsen. Example: Exposure to cold and damp can exacerbate the symptoms of a sinus infection. Enhance—augment. Example: Comfort measures such as clean linen, a back rub, and pleasant music can enhance the action of pain medications. Excessive—more than acceptable, exorbitant. Example: The bleeding was excessive following the surgery. CHAPTER 2 Test and Language Basics 13 Expectorate—cough up and spit out mucus. Example: To prevent spread of infection, the nurse instructed the client to expectorate into a tissue and dis- pose of it in the provided plastic bag. Flushed—any tinge of red. Example: The client’s face was flushed and he was warm to the touch. Flaccid—without resistance. Example: A flaccid muscle is one with less than normal tone. Tense—rigid, feeling nervous. Examples: A sign of increased intracranial pressure in a neonate is a tense fontanelle. The client complained of feeling extremely tense when- ever an interview with the psychiatrist was scheduled. Hoarseness—grating sounds. Example: Hoarseness is a characteristic symptom of laryngitis. Impinge—come into close contact. Example: The CAT scan showed that the tumor was impinging on the recurrent laryngeal nerve thus accounting for the hoarseness. Inept—not apt, unable to do well. Example: The client remained inept at handling the insulin syringe, so additional teaching was planned. Insulation—prevent transfer of electricity, heat, or sound. The insulation in the walls of hospital rooms helps clients to rest by decreasing nose heard from other areas of the unit. Intact—without injury. Example: The client’s skin remained intact despite the long period of bed rest. Isolation—loneliness, separation. Examples: Clients having intracavitary radiation treatments are at risk for feelings of isolation. Clients presenting with active, drug resistant tuberculo- sis are placed in isolation. Lead to—results in. Example: An untreated streptococcal sore throat can lead to glomerulonephritis in susceptible children. Least likely—in the smallest degree, lowest chance. Example: The client least likely to develop constipa- tion is the one with a liberal fluid and roughage intake, who exercises regularly, and obeys the urge to defecate. Most likely—to the greatest degree, highest chance. Example: Of antibiotics, diuretics, or calcium channel blockers, the drugs most likely to cause allergic reactions are the antibiotics. 14 PART I: Testing Smart Liberally—freely, unchecked. Example: The client should be encouraged to use the Calamine lotion liberally to control the itch of the poison ivy. Predispose—create a tendency to. Example: Use of immunosuppressant drugs predisposes the client to infection. Permit—let. Example: Elevating a Foley catheter drainage bag above the level of the client’s pelvis permits backflow of urine into the bladder. Profuse—pouring forth. Example: Vaginal drainage was yellow, profuse, and malodorous. Refrain—keep oneself from doing. Example: The client was instructed to refrain from lift- ing anything over 5 lbs following repair of his hernia. Sparingly—frugally. Example: It is important to apply the skin preparation sparingly in accordance with the directions. Spasm—involuntary contracture. Example: The client complained of repeated leg spasms during the night. Sedentary—physically inactive. Example: A sedentary lifestyle predisposes to obesity. Check your basic test vocabulary by completing the fol- lowing vocabulary exercise. WORKSHEET 2: VOCABULARY Directions: Match the definitions in column B with the words in column A. Column A 1. ____Site 2. ____Coarse 3. ____Imminent 4. ____Deficient 5. ____Former 6. ____Enhance 7. ____Impinge 8. ____Tense 9. ____Predispose 10. ____Sedentary 11. ____Except 12. ____Principal 13. ____Loose 14. ____Exacerbate 15. ____Profuse Column B a. something to be left out b. progress c. without intending to d. rough e. create a tendency to f. saturate g. location h. a truth i. at any time j. unable to do well k. inactive l. shaky m. opposite of tight n. eliminate o. pouring forth p. easy going q. of major importance r. cause discomfort s. rigid t. worsen u. about to happen v. first of two w. misplace x. augment y. lackof z. come into close contact WORKSHEET 3 CHAPTER 2 Test and Language Basics 15 QUESTIONS Do you have key facts from this chapter on your NCLEX-RN knowledge ring? Complete the worksheet below to help you check. Directions: For items 1 to 5, read each question. If the question contains a key word, underline it. 1. Which nursing intervention should be given priority in the plan of care for a client with newly diagnosed tuberculosis? 2. In formulating a teaching plan for home care of a client with lung cancer, which information is most essential to include about the use of oxygen? 3. In caring for a client receiving outpatient chemotherapy for metastatic breast cancer, which instruction should the nurse include about the care of the central line? 4. When administering an IM medication using Z-track technique, what is the next step the nurse should take after injecting the medication into the muscle? 5. When assessing a client’s response to Toprol XL, which finding would be unexpected? Directions: For items 6 through 10, read each sentence carefully and decide if the underlined word is used correctly or incorrectly in the sentence. Write Correct or Incorrect at end of each sentence. 6. The client’s nutritional status was compromised when he eliminated almost all sources of protein from his diet. 7. The nurse reported that the client was inept after reviewing laboratory reports that showed immunosuppression. 8. The medication allayed the pain as indicated by the client’s statement that her pain was almost gone. 9. On first encountering a client, statute should be noted as part of the general assessment survey. 10. After the client drew up the incorrect amount of insulin and then contaminated the needle, the nurse concluded that the client needed farther teaching. ANSWERS & RATIONALES ANSWERS FOR WORKSHEET 1: IDENTIFICATION OF KEY WORDS Directions: Read each of the following questions. If the question contains a key word, underline it. 1. Which clinical manifestation would the nurse expect when assessing a client admitted with a diagnosis of bacterial pneumonia? Answer Which clinical manifestation would the nurse expect when assessing a client admitted with a diagnosis of bacterial pneumonia? (continued) 16 PART I: Testing Smart 2. Which sign should alert the nurse to a potential problem in a client with a history of a CVA? Answer Which sign should alert the nurse to a potential problem in a client with a history of a CVA? 3. What is the primary goal for the hospice care of a client with lung cancer? Answer What is the primary goal for the hospice care of a client with lung cancer? 4. Which nursing intervention should be given priority in the plan of care for a teenager with sickle cell anemia? Answer Which nursing intervention should be given priority in the plan of care for a teenager with sickle cell anemia? 5. The nurse is assessing the nutritional status of a client who is 3 months pregnant. Which information is most impor- tant for the nurse to obtain? Answer The nurse is assessing the nutritional status of a client who is 3 months pregnant. Which information is most important for the nurse to obtain? 6. The nurse is obtaining a health history of a debilitated client with sacral pressure ulcers. Which question should the nurse ask to elicit information effectively about the client’s dietary intake? Answer The nurse is obtaining a health history of a debilitated client with sacral pressure ulcers. Which question should the nurse ask to elicit information effectively about the client’s dietary intake? 7. Which behavior by a client with a newly created colostomy should alert the nurse to the need for teaching regarding skin care? Answer Which behavior by a client with a newly created colostomy should alert the nurse to the need for teaching regarding skin care? No keyword. 8. What is the best way to assess for shortness of breath in a 3-year–old client with congenital heart disease? Answer What is the best way to assess for shortness of breath in a 3-year–old client with congenital heart disease? 9. The nurse is assessing a family’s ability to provide emotional support to a family member diagnosed with cancer. Which observation is most essential? Answer The nurse is assessing a family’s ability to provide emotional support to a family member diagnosed with cancer. Which observation is most essential? 10. In analyzing the need for teaching a teenage primipara, the clinic nurse should ask which question? Answer In analyzing the need for teaching a teenage primipara, the clinic nurse should ask which question? No keyword. 11. Which finding should the nurse expect when checking urinary output of a client with SIADH? Answer Which finding should the nurse expect when checking urinary output of a client with SIADH? 12. Which information would be most helpful when preparing to do a home assessment prior to discharge of a low birth weight newborn? Answer Which information would be most helpful when preparing to do a home assessment prior to discharge of a low birth weight newborn? CHAPTER 2 Test and Language Basics 17 13. Why is it important to monitor pulse rate in a client on digoxin? Answer Why is it important to monitor pulse rate in a client on digoxin? No keyword. 14. A 25-year–old woman comes to the clinic complaining of lower left abdominal pain. Which additional information should the nurse obtain initially? Answer A 25-year–old woman comes to the clinic complaining of lower left abdominal pain. Which additional information should the nurse obtain initially? 15. Which assessment question should receive priority? Answer Which assessment question should receive priority? ANSWERS FOR WORKSHEET 2: VOCABULARY Column A Column B 1. _g__Site 2. _d__Coarse 3. _u__Imminent 4. _y__Deficient 5. _v__Former 6. _x__Enhance 7. _z__Impinge 8. _s__Tense 9. _e__Predispose 10. _k__Sedentary 11. _a__Except 12. _q__Principal 13. _m__Loose 14. _t__Exacerbate 15. _o__Profuse a. something to be left out b. progress c. without intending to d. rough e. create a tendency to f. saturate g. location h. a truth i. at any time j. unable to do well k. inactive l. shaky m. opposite of tight n. eliminate o. pouring forth p. easy going q. of major importance r. cause discomfort s. rigid t. worsen u. about to happen v. first of two w. misplace x. augment y. lackof z. come into close contact 18 PART I: Testing Smart ANSWERS FOR WORKSHEET 3 Do you have key facts from this chapter on your NCLEX-RN knowledge ring? Complete the worksheet below to help you check. Directions: For items 1 to 5, read each of the following questions. If the question contains a key word, underline it. 1. Which nursing intervention should be given priority in the plan of care for a client with newly diagnosed tuberculosis? Answer Which nursing intervention should be given priority in the plan of care for a client with newly diagnosed tuberculosis? 2. In formulating a teaching plan for home care of a client with lung cancer, which information is most essential to include about the use of oxygen? Answer In formulating a teaching plan for home care of a client with lung cancer, which information is most essential to include about the use of oxygen? 3. In caring for a client receiving outpatient chemotherapy for metastatic breast cancer, which instruction should the nurse include about the care of the central line? Answer No keyword. 4. When administering an IM medication using Z-track technique, what is the next step the nurse should take after injecting the medication into the muscle? Answer When administering an IM medication using Z-track technique, what is the next step the nurse should take after inject- ing the medication into the muscle? 5. When assessing a client’s response to Toprol XL, which finding would be unexpected? Answer When assessing a client’s response to Toprol XL, which finding would be unexpected? Directions: For items 6 through 10, read each sentence carefully and decide if the underlined word is used correctly or incorrectly in the sentence. Write Correct or Incorrect at end of each sentence. 6. The client’s nutritional status was compromised when he eliminated almost all sources of protein from his diet. Correct 7. The nurse reported that the client was inept after reviewing laboratory reports that showed immunosuppression. Incorrect, inept means unable to do well. The client was inept at changing his dressing is a correct use of the term. 8. The medication allayed the pain as indicated by the client’s statement that her pain was almost gone. Correct 9. On first encountering a client, statute should be noted as part of the general assessment survey. Incorrect, the word should be stature. 10. After the client drew up the incorrect amount of insulin and then contaminated the needle, the nurse concluded that the client needed farther teaching. Incorrect, the word should be further. Sharpening Your Test-Taking Skills To be as sharp as possible when answering test questions, follow these steps: • Identify the parts of a question —the scenario which tells you about the situation —the stem which contains the actual problem/question to be answered —for multiple choice questions, the options or alterna- tives, which consist of one correct answer (the key) and three distracters or incorrect answers. Distracters some- times answer a different question than the one asked in the stem or they may assume information not provided in the stem. As a result, they can seem like a good choice and hence are good distracters. Remember that if any part of an option is incorrect, the whole answer is wrong. • Read the words in the question carefully. Identify “tricky” English words and think about their meaning. Jot down the meaning over each such word and then reread using the definition. • Determine what the question is asking—read twice and try rephrasing it in easier terms. Once you identify the specific question and its subject, then you can focus on what you know about it. • Identify what facts provided in the stem or scenario are relevant to the question. • Ask if the option makes sense for this client—eliminate the option from consideration if the answer is No—even if under other circumstances it is a high-priority action. • Lookforkeywords—thosethatdirecttheanswer—whenyou read the question. Take special note of a negative key word. • As you read the question, think of your answer and then see if it is among the choices. Do not select the first answer that looks right; however, read all the options carefully. • Always select an answer within the RN scope of practice. Example: Which of the following is a basic nursing responsibility related to drug administration? 1. Monitoring the client’s response to the administration of the drug Correct 2. Determining the appropriate drug dosage 3. Selecting the best route of administration of the drug 4. Ordering the drug from the pharmacy • When not certain of an answer, select the most complete option. Example: Which is the best definition of a medication? 1. Chemical that treats symptoms of disease 2. Drug used for a therapeutic effect Correct 3. Pharmacological preparation used to reverse disease 4. Plant, animal, or mineral substance which prevents disease • Do not change your answer unless you are certain it is incorrect. APPROACHES TO SPECIFIC TYPES OF QUESTIONS Questions That Require Priority Setting Guidelines for establishing priorities are as follows: • The nurse should always assess (gather pertinent data) before deciding on and taking an action. This is reflected in the steps of the Nursing Process: assess, diagnose, plan, intervene, and evaluate. • Physiological needs must be met first. The client must be kept alive for anything else to be important. Next in importance are safety needs and then come psychological needs. This is outlined in Maslow’s hierarchy. • When prioritizing physiological needs remember your ABCs: airway, breathing, and circulation. • Which answer will keep the client safe/prevent client harm? It is especially relevant when the question deals with laboratory values, drug administration, and nursing procedures. • Assessment of equipment never takes precedence over assessment of the client. Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use. 19 CHAPTER 3 20 PART I: Testing Smart Communication Questions Therapeutic communication promotes expression of feelings and ideas and also conveys acceptance and respect. Like any communication, it involves both verbal and nonverbal com- ponents. Major techniques to facilitate therapeutic commu- nication are as follows: • Communicate in an accepting and respectful manner. Address (refer to) the client by his/her given name—not by a nickname, a room number, or “sweetie.” Names other than the given name should only be used upon the client’s request or permission. Clients should be asked, not told, whenever appropriate. This allows for client decision making and hence communicates respect for the client as an able, intelligent individual. Examples: What would you like to do first? What would you like to talk about? • Use open-ended questions. These are questions that can- not be answered with a Yes or a No. Examples: What do you think about this plan? What questions do you have? How do you feel about going home tomorrow? Tell me about your headaches. • Reflect feelings expressed by the client. Remember that feelings are expressed verbally and nonverbally. These may be contradictory but feelings expressed nonverbally are usually true because nonverbal communication is harder to control. Reflection indicates empathy, allows validation of the perceived feelings, and allows the client to “look at” his/her feelings. Words used in reflection should be neutral unless the client uses an emotionally charged word. Examples: You seem sad. You seem unsure. You must feel lonely sometimes. I get the feeling you are upset. Do not say: You are depressed. You can’t make a decision. It must be awful being alone all the time. You must be really mad at your neighbor. • Focus the conversation on important areas. Examples: Let’s talk a little more about . . . You were talking about the problem you had with chang- ing your dressing, let’s go back and explore that further. • Paraphrase or restate what the client has said in your own words. This allows the client to validate the message or correct misunderstanding. Examples: What you are saying is . . . Let me make sure I understand . . . What I hear you saying is . . . • Summarize the communication. Therapeutic communication also involves (a) active listening, (b) stating observations made about the client but never any that would embarrass or anger the client (“You look rested” or “You seem quiet today.” Not “You look terrible.”), (c) reflecting empathy or an understand- ing of the importance of a situation to the client in a neu- tral, nonjudgmental manner (“It must be very dishearten- ing . . .”), (d) sharing hope, humor, and feelings, (e) using touch and silence, (f ) asking pertinent questions, and (g) giving information. Nontherapeutic (blocking) communication techniques hinder further communication and expression of feelings and may induce negative responses. Some examples of non- therapeutic communication techniques are: • Asking unnecessary personal questions: “Why are you just living with Mary rather than marrying her?” “Why are you still living at home?” “How come you haven’t bought a house?” • Giving personal advice or opinions: “If I were you I would make my son move out.” “I think you should stop cooking for the whole family.” • Flip or automatic responses, use of cliches: “Everything will work out.” “Don’t worry.” “It happens all the time but it doesn’t mean anything.” Redirecting the conversation or changing the subject, expressing sympathy, asking “why,” verbalizing approval or disapproval, responding defensively, passively or aggressively, and arguing also block therapeutic communi- cation. When answering a communication question, begin by reviewing the above principles. Then determine what the question is asking. If the question is asking what is the nurse’s best response, what is the most appropriate response, what is the most therapeutic response, or what response will best support a therapeutic relationship, eliminate nonthera- peutic options. Do this by identifying options that involve nontherapeutic responses: options that give opinions, options that brush off the client’s concerns; options that con- tain emotionally charged, defensive, accusatory, or otherwise upsetting or offensive wording, and options that contain judgmental wording. Example: A client who has been hospitalized for 2 weeks says to the nurse “I can’t stay here anymore, I have to get back to my family.” Which is the most appropriate response for the nurse to make? a. “Don’t worry. Your family will be fine.” b. “If I were you, I’d take advantage of the rest you’re get- ting while away from the family.” c. “Would you like to talk about how you feel?” Correct d. “Is your family unable to get along without you?” In some cases, the question may be asking you to iden- tify the nontherapeutic or inappropriate response. Be alert for this when reading questions and then select the option containing a response that would be incorrect for the nurse to make as the answer. Example: A client states “My family doesn’t seem to understand my illness.” Which response on the part of the nurse would most likely block further discussion? a. “They may not seem to, but I’m sure they do.” Correct b. “In what way do they react to give you that feeling?” c. “Your family doesn’t seem to understand.” d. “What makes you think that?” Client-Teaching Questions There are different types of client-teaching questions. Some are very straightforward simply asking what should the nurse teach. This type of question addresses the planning or implementation phase of the nursing process. Example: Which instruction/information should the nurse include in the teaching plan for a client with genital herpes? Which instruction/information should the nurse give to a client with genital herpes? A variation on this type of question asks you to identify not what needs to be taught but when or by whom, teaching is needed. Example: Which client should be taught about the need for potas- sium in the daily diet? a. Client taking daily NSAIDS for arthritis b. Client taking Toprol XL daily for hypertension c. Client taking Fosamax weekly for osteoporosis d. Client taking Hydrodiuril daily for fluid retention Correct Other client-teaching questions ask not what should be taught but how does the nurse know the teaching was understood. These are client-teaching questions that address the evaluation phase of the nursing process. Was the teach- ing effective? Did the client learn? These questions may be phrased in a positive or negative way. Positive questions ask you to select an answer that is a correct statement or activity—something that should be done or said. Examples of positively phrased questions: Which statement made by a client with hepatitis B fol- lowing discharge teaching indicates that instruction was effective? Which statement made by a client with hepatitis B indi- cates that discharge instructions were understood? Negatively phrased questions ask you to identify the answer that indicates the client does not know, has misun- derstood, or has not learned. It requires that you identify an incorrect statement—not a correct one. Negative questions require that you choose from the options the one that is incorrect or should not be said or done. Note that negative questions do not necessarily have a negative word (not, no, incorrect, etc.) in the stem. Examples of negatively phrased questions: Which statement made by a client taking Fosamax once a week for the treatment of osteoporosis indicates that the directions for taking the medication were not under- stood? Which action taken by a client who has been taught to self-administer insulin indicates that further teaching/ instruction is necessary? Which statement made by the mother of a child diagnosed with bronchiolitis indicates a need for teaching? A client’s daughter is assisting her to the bathroom. Which observation by the nurse suggests that teaching is needed? Delegation Questions These typically ask what duties can be assigned to a nurse aide or an LPN/LVN and when a physician, social worker, respiratory therapist, or other member of the health-care team should be notified or consulted. CHAPTER 3 Sharpening Your Test-Taking Skills 21 22 PART I: McGraw-Hill Review for the NCLEX-RN® Examination WORKSHEET IDENTIFYING FACILITATING AND BLOCKING RESPONSES Directions: Read each statement or set of statements and decide if therapeutic communication is being facilitated or blocked. Write your decision at the end of each. 1. Client: “I’m so worried about my surgery.” Nurse: “We do 10 of these procedures every week and they all come out fine.” 2. Client: “I keep thinking about my husband and how he is managing at home by himself.” Nurse: “You just have to put him out of your mind and concentrate on getting better.” 3. Client: “I don’t know how I am going to cope with all the bills from being in the hospital.” Nurse: “I’ll have a social worker stop by to go over your insurance.” 4. Client’s daughter: “I don’t know how I am going to arrange care for my mother at home while I work.” Nurse: “If it were me I would put her in a nursing home where she would have round-the-clock care.” 5. Client: “I am such a burden on everybody since I had the stroke.” Nurse: “What makes you say that?” 6. Client:“I’llneverlearnhowtogivemyselfthisinjection.” Nurse: “Of course you will.” 7. Infantclient’smother:“I’mafraidthatIwillforgethowto correctly prepare the baby’s formula when I get home.” Nurse: “Would you like me to go over the procedure with you one more time?” 8. Client: “Having that test was the worst experience I’ve had in my whole life.” Nurse: “Tell me what happened.” 9. Client: “I have to begin to have my husband help with the housework when I get home.” Nurse: “Do you have a plan in mind as to how you are going to do this?” 10. Client: “I can’t use a diaphragm anymore; it’s just too messy and inconvenient.” Nurse: “Would you like information on other forms of birth control?” 11. Client: “My son doesn’t want to visit me anymore. He says I am always complaining.” Nurse: “Children expect their parents to be perfect. He’ll get over it.” 12. Client: “I can’t do anything right.” Nurse: “You shouldn’t feel that way. Things will be different when you’re better.” 13. Client: “I am so upset about my roommate’s visitor tripping over my slippers yesterday.” Nurse: “My advice to you is to forget it—she didn’t get hurt.” 14. Client: “My son-in-law refused to bring my grand- daughter to visit me.” Nurse: “That’s mean; it must make you angry.” 15. Client: “I don’t think I am going to make it out of here. I am just so weak.” Nurse: “You are very depressed.” ANSWERS & RATIONALES IDENTIFYING FACILITATING AND BLOCKING RESPONSES Directions: Read each statement or set of statements and decide if therapeutic communication is being facili- tated or blocked. Write your decision at the end of each. 1. Client: “I’m so worried about my surgery.” Nurse: “We do ten of these procedures every week and they all come out fine.” Blocked. This response provides false reassurance and may even be interpreted as flip. It does not acknowl- edge the client’s concern nor encourage further sharing. 2. Client: “I keep thinking about my husband and how he is managing at home by himself.” Nurse: “You just have to put him out of your mind and concentrate on getting better.” Blocked. This response does not acknowledge the client’s concern and is a form of personal advice. It effectively shuts off further discussion. CHAPTER 3 Sharpening Your Test-Taking Skills 23 3. Client: “I don’t know how I am going to cope with all the bills from being in the hospital.” Nurse: “I’ll have a social worker stop by to go over your insurance.” Blocked. This response indicates that the topic of the client’s concern has been heard but it offers a solution which may or may not be acceptable to the client. It does not offer the client a choice or the opportunity to further specify or discuss concerns or feelings. 4. Client’s daughter: “I don’t know how I am going to arrange care for my mother at home while I work.” Nurse: “If it were me I would put her in a Nursing Home where she would have round the clock care.” Blocked. This response gives advice and shuts down fur- ther discussion of the problem. 5. Client: “I am such a burden on everybody since I had the stroke.” Nurse: “What makes you say that?” Facilitated. This is an open ended question that encour- ages the client is to explore his or her feelings. 6. Client: “I’ll never learn how to give myself this injec- tion.” Nurse: “Of course you will.” Blocked. This response gives false reassurance and con- stitutes a cliché. 7. Infant Client’s Mother: “I’m afraid that I will forget how to correctly prepare the baby’s formula when I get home.” Nurse: “Would you like me to go over the procedure with you one more time?” Facilitated. This response recognizes the mother’s concern and offers, not dictates, an appropriate option. 8. Client: “Having that test was the worst experience I’ve had in my whole life.” Nurse: “Tell me what happened.” Facilitated. This response indicates willingness to hear the client and encourages exploration of feelings and events. 9. Client: “I have to begin to have my husband help with the housework when I get home.” Nurse: “Do you have a plan in mind as to how you are going to do this?” Facilitated. This question can be answered yes or no but it opens the for the nurse to guide the client in the dis- cussion and evaluation/revision/development of a plan. 10. Client: “I can’t use a diaphragm anymore; its just too messy and inconvenient.” Nurse: “Would you like information on other forms of birth control?” Facilitated. This response recognizes the client’s concern and offers an appropriate option in response. 11. Client: “My son doesn’t want to visit me anymore. He says I am always complaining.” Nurse: “Children expect their parents to be perfect. He’ll get over it.” Blocked. This response is cliché in nature and does not recognize the validity of the client’s concern. 12. Client: “I can’t do anything right.” Nurse: “You shouldn’t feel that way. Things will be different when you’re better.” Blocked. This response although somewhat “gentle” in its wording, offers false reassurance, may be construed as judgmental, and does not allow the client to further explain his or her feelings and concerns. It also contains an element of cliché. 13. Client: “I am so upset about my roommate’s visitor tripping over my slippers yesterday.” Nurse: “My advice to you is to forget it - she didn’t get hurt.” Blocked. This response offers advice and trivializes the client’s concern. 14. Client: “My son in law refused to bring my grand daughter to visit me.” Nurse: “That’s mean; it must make you angry.” Blocked. This response is judgmental and presumes to know what the client is feeling. 15. Client: “I don’t think I am going to make it out of here. I am just so weak.” Nurse: “You are very depressed.” Blocked. This response makes a judgment about the client. It does not encourage the client to discuss feelings not does it seek to validate interpretation of the client’s communication. This page intentionally left blank CONTENT REVIEW Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use. Part II This page intentionally left blank CHAPTER 4 Advanced Directives 31 Case Management 40 Client Rights 29 Concepts of Management 33 Confidentiality/Information Security 30 Consultation 39 Continuity of Care 38 Delegation 37 Establishing Priorities 38 Ethical Practice 32 Informed Consent 31 Legal Rights and Responsibilities 28 Performance Improvement (Quality Improvement) 41 Resources 39 Resource Management 40 Staff Education 42 Test Plan Category: Safe, Effective Care Environment Sub-category: Management of Care Topics: Legal Rights and Responsibilities Client Rights Information Technology Confidentiality/Information Security Informed Consent Advance Directives Ethical Practice Concepts of Management Delegation Establishing Priorities Supervision Continuity of Care Resource Management Collaboration with the Multidisciplinary Team Advocacy Referrals Case Management Consultation Performance Improvement/ Quality Improvement Staff Education Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use. 27 28 PART II: Content Review LEGAL RIGHTS AND RESPONSIBILITIES PROFESSIONAL LEGAL ISSUES Legal controls on the practice of nursing are to protect the public. Law provides a framework for • identifying what nursing actions are legal, • differentiating the nurses’ responsibilities from those of other health care professionals, • establishing the boundaries of independent nursing actions, and • assisting in maintenance of a standard of nursing practice. Nurse Practice Act • This is a set of laws defining the scope of nursing practice. • Each state has its own Nurse Practice Act usually adminis- tered by the State Board of Nursing. • Most Nurse Practice Acts address performing services for compensation, specialized knowledge bases, use of the nursing process, and components of nursing practice. Practice Alert The nurse needs to obtain and read the Nurse Practice Act for the state that she/he intends to practice in. Licensure • License is a legal credential conferred by a state granting permission to an individual to practice a given profession. • It is commonly required for professions requiring direct contact with clients. • Licensure requires that a level of competency be demon- strated by the individual seeking a license; for an RN license this is done by passing the NCLEX-RN. • Mandatory licensure for registered nursing is the standard in the United States—one must have a valid nursing license to work in any state, territory, or province. • RN Nurse Licensure Compact (NLC) is a mutual recogni- tion licensure model which allows a nurse to be licensed in his or her state of residence but to practice physically or electronically in other ccompact states. Practice in compact states is subject to each state’s practice law and regulation. • Each state or jurisdiction establishes its own licensing laws, which usually require graduation from an approved nursing educational program, passing score on the NCLEX-RN, a good moral character, good physical and mental health, and disclosure of criminal convictions. Standards of Care • Standards of care are authoritative statements that define an acceptable level of patient care (professional practice). • These are used to evaluate the quality of care provided by the nurse and, therefore, become legal guidelines for nurs- ing practice. • American Nurses Association (ANA) has developed gen- eral standards and guidelines for more than 20 specialty nursing practice areas. • State Nurse Practice Acts describe standards of practice that apply to a nurse in the particular state. • Individual health care agencies may have developed stan- dards of care for selected patient problems, e.g., critical pathways, clinical pathways. Malpractice • Malpractice is the term used when a nurse while perform- ing her/his responsibilities commits an act of negligence resulting in harm to the patient. • Harm must be based on the failure to act in a prudent pro- fessional manner and within professional standards. • Nurse must have had a professional duty toward the per- son receiving the care for malpractice to have occurred. Practice Alerts Regulation of the practice of nursing serves two purposes: protection of the public and accounta- bility of the individual practitioner’s actions. Malpractice is present only if a breach of duty was the cause of the injury. LEGAL ISSUES AFFECTING PATIENTS Legal issues affecting patients are those that occur when a wrong has been committed against a patient or a patient’s property. Defamation of Character • Defamation of character occurs when information about an individual is detrimental to his/her reputation. • The communication, which is considered to be malicious and false, may be spoken (slander) or written (libel) and may be about patients or other health care providers. • The nurse must —document only objective information in the medical record, —use professional terms, —avoid discussing patients and other health care providers in public places where there is the possibility of being overheard, and —use only acceptable avenues to confidentially report behavior of patients or other health care providers. Privileged Communication • Privileged communication is the information shared by an individual with certain professionals and that does not need to be revealed in a court of law. • The nurse needs to know what the state she/he is practic- ing in says about privileged communications. Practice Alert All states do not recognize the nurse–patient rela- tionship as one of privileged communication. States that do recognize the relationship as privi- leged may not recognize all communications between patient and nurse as privileged. Emergency Care • Certain actions provided by a health care professional may be legal in emergency situations and not legal in nonemer- gency situations. • During a true emergency, consent is implied as the court considers that a reasonable person in a life-threatening sit- uation would give permission for treatment. • “Good Samaritan Acts” protect the nurse against negli- gence when she/he provides voluntary assistance to an individual in an emergency situation. • Within a health care agency, the emergency policies and procedures of the institution govern what the nurse can do, and so a nurse must know these. The courts have held that a nurse can do things immediately necessary, even if the activity is normally considered a medical function, provided she/he has the expertise to carry out the act. The nurse is protected from a charge of practicing outside the scope of practice if the protocols established by the institu- tion’s medical staff are followed. Practice Alert Hospitals and health care agencies are expected to have policies and protocols to be followed dur- ing an emergency situation, e.g., “code.” The standard of “reasonable care” is used when emer- gency care is given in a noninstitutional setting. Refusing Treatment • This issue arises out of the belief in and respect for the autonomy of the patient. • The two forms of refusing treatment are when the patient discharges himself/herself from the hospital against med- ical advice or when he/she refuses certain treatment when in the hospital. CHAPTER 4 Safe, Effective Care Environment 29 Patients have the right to expect they will be treated in a cer- tain way, receive adequate information, and have their confi- dentiality maintained when they are interacting with the health care system. DIGNITY • Dignity is the right to receive compassionate nursing care. • It is an essential professional nursing value. • The nurse demonstrates respect for the worth and unique- ness of individuals—patients and colleagues. • The nurse advocates for the respect and dignity of human beings. AUTONOMY • Autonomy is the right of self-determination. • The nurse must respect the patient’s right to make deci- sions about and for himself/herself. • Examples of respect for an individual’s autonomy are obtaining informed consent, facilitating patient choice for treatment, allowing patient to refuse treatment, and main- taining confidentiality. • Individuals may lose autonomy when they fall ill; family interactions may leave the patient out of the decision- making process. CLIENT RIGHTS 30 PART II: Content Review PATIENT’S BILL OF RIGHTS • This document was developed by the American Hospital Association (AHA) in 1972 and was revised in 1992. • It outlines an individual’s right to inspect his/her medical record and to receive information about the medical care received during a hospital stay. In addition, the Bill speaks for the right to respectful care, relevant and understandable information, advance directive, consideration of privacy, consent or decline participation in research, continuity of care, and information of hospital policies and practices. • In 2001, the McCain-Edwards-Kennedy/Ganske-Dingell Patients’ Bill of Rights was passed. The Bill addresses such additional issues as shared decision making, the right to be informed of all medical options, and the right to refuse treatment. ACCESS TO MEDICAL RECORD The medical record • contains medical information as well as personal informa- tion about the patient. • is considered the property of the health care agency, but the patient has a legal interest and right to the information. • can be accessed by those with a legitimate interest, which is generally accepted as referring to patient care, profes- sional education, administrative functions, auditing func- tions, research, public health reporting, and criminal law requirements. Practice Alert Information may be shared between health care providers who are responsible for patient care within a health care facility. Health care agencies have a responsibility to establish policies and pro- cedures to protect patient confidentiality as well as falsification or alteration of the medical record. Nurses are held accountable for upholding the Patient’s Bill of Rights. Under conditions of dan- ger to another human being, autonomy would not be absolute. CONFIDENTIALITY/INFORMATION SECURITY A patient’s privacy will be respected and information that is shared about a patient to a health care provider will not be made public without the patient’s consent. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) • The Act is a federal privacy standard that protects the patient’s medical records and other identifiable health information whether maintained on paper, computer, or orally communicated. • It requires the maintenance of confidentiality and ensures the privacy of patients. • Patients can obtain copies of their medical records. • Providers must provide patients with written notice of practices and patients’ rights. • Limitations are placed on information shared: what, where, and with whom. COMPUTERIZED MEDICAL DATABASE • Serious concern arises around patient privacy and confi- dentiality as health care information becomes more and more electronically accessible. • ANA supports nine principles in keeping with patient advocacy and trust in regard to advances in technology and patient’s health information. Practice Alert Health care agencies need to have policies and procedures in place to ensure privacy and confi- dentiality of computerized patient information. Ultimately, patients will have increased control over their own information and there will be significant penalties in place if the policies are violated. • An individual has the right to understand the choices being offered around medical treatment and the right to voluntarily agree or refuse treatment. • The client must receive a description of the procedure, alternatives for treatment, risks involved in treatment, and probable results. The law holds obtaining consent for medical treatment to be the responsibility of the physician, but the nurse has a responsibility of notifying the physician if she/he determines that the client does not seem to understand. • Consent can be oral or written, although a written