Answers
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
Document communication with the client related to items left within the room
Valuables should be locked in the facilities safe
Identify negligence - CORRECT ANSWER-Failure to provide care as defined by a standard
Breach of duty
Foreseeability of harm
Caused harm
Latex allergy - CORRECT ANSWER-Schedule first on the morning operating list (OR must be free from
powdered latex gloves for at least 3 hours prior to surgery)
Synthetic gloves must be used
Furniture in operating room equipment must be washed down using synthetic gloves only
Anything containing latex must be removed from the OR