Questions With Complete Solutions
Advance directives- teaching correct answer: Communicates the client wishes regarding end of life care; are written before a client becomes ill
Nurses role is to provide info about advance directives
Document client's advance directive status
Ensure advance directives reflects clients current decision
Inform all members of the healthcare team of the client's advanced directives
Culture (client who speaks a different language) correct answer: Use an interpreter always; try to get someone around same age and gender as client
Delegation to UAP correct answer: Stable/chronic clients; post-
mortem care; they cannot teach, assessed, or evaluate
Ethical (client need for information about treatment) correct answer: Provide client with truthful information so they can make an informed decision about their own health and well-
being Discharge planning correct answer: Determine ability to afford insulin and supplies
Make sure he has transportation to follow up appointments
Informed consent correct answer: Nurses role is to witness the client signature and ensure that the provider has obtained the informed consent responsibly
Greater than 18 years of age or if the mother or father is a teenage parent they have the right to sign the consent form
Client inquiry about surgery correct answer: Consult health care
provider/surgeon for procedures/informed consent questions
Telephone prescriptions are correct answer: Must write the order down before reading it back to the provider
Identify Improper documentation correct answer: Documenting should be factual
Subjective data documentation correct answer: Quotes with quotation marks- what the client states to the nurse
Objective data documentation correct answer: What the nurses, smells, osculates do not use derogatory words, judgment, or opinions
Intentional tort correct answer: Doing harm (The act must be intentional, not merely reckless or careless)
Assault, battery, false imprisonment, invasion of privacy, slander Interprofessional team member consult correct answer: PT- consulted for mobility issues
OT- assist clients to regain ADL skills
ST- Deals with speech and language disorders
Coordinated client care among healthcare team correct answer: Social worker- Coordinates care and community resources
Demonstrating client advocacy correct answer: Nurses role is to
provide support of the clients health, wellness, safety, and personal rights, including privacy
Nursing role- client observation correct answer: Share appropriate information among team members
Prioritizing client care correct answer: Follow ABC's (airway, breathing, circulation)
Unstable are seen before stable clients
Acute clients are seen before chronic clients
Ethical dilemma correct answer: Follow autonomy, beneficence, Fidelity, justice, nonmaleficence, and veracity principles
Disposition of valuables
(Admit/transfer/DC) correct answer: Personal items include clothing, jewelry, money, credit cards, hearing aides, eyeglasses,
dentures, etc
Discourage the client from keeping valuables at bedside