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Ch. 5) A charge nurse is reviewing documentation with a group of
newly licensed nurses. Which of the following legal guidelines should
be followed when documenting in a client's record? (Select all that
apply.)
A. Cover errors with correction fluid, and write in the correct
information.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
D. Use as many abbreviations as possible.
E. Wait until the end of the shift to document. - ANSWER- B, C
Rationale:
B. The date and time confirm the recording of the correct sequence of
events
C. Documentation must be factual, descriptive, and objective,
without opinions or criticism
Ch. 3) A nurse is caring for a client who decides not to have surgery
despite significant blockages of the coronary arteries. The nurse
understands that this client's choice is an example of which of the
following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence - ANSWER- B
,Rationale: in this situation the client is exercising their right to make
their own personal decision about surgery, regardless of others opinions
of what is best for them. This is an example of autonomy
Ch. 3) A nurse offers pain medication to a client who is postoperative
prior to ambulation. The nurse understands that this aspect of care
delivery is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficence - ANSWER- D
Rationale: Beneficence is an action that promotes good for others
without self interest. By administering pain medication before the client
attempts a potentially painful exercise like ambulation, The nurse is
taking a specific and positive action to help the client
Ch. 3) A nurse is instructing a group of newly licensed nurses about the
responsibilities organ donation and procurement involve. When the
nurse explains that all clients waiting for a kidney transplant have to
meet the same qualifications, the newly licensed nurses should
understand that this aspect of cared delivery is an example of which of
the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence - ANSWER- C
Rationale: justice is fairness in care delivery and in the use of resources.
By applying the same qualifications to all potential kidney transplant
recipients, organ procurement organizations demonstrate this ethical
principle in determining the allocation of these scarce resources
,Ch. 3) A nurse questions a medication prescription as too extreme in
light of the client's advanced age and unstable status. The nurse
understands that this action is an example of which of the following
ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence - ANSWER- D
Rationale: Non-malfeasance is a commitment to do no harm. In this
situation, administering the medication could harm the patient. By
questioning it, the nurse is demonstrating the ethical principle
Ch. 3) A nurse is instructing a group of newly licensed nurses about how
to know and what to expect when ethical dilemmas arise. Which of the
following situations should the newly licensed nurses identify as an
ethical dilemma?
A. A nurse on a medical-surgical unit demonstrates signs of chemical
impairment
B. A nurse overhears another nurse telling an older adult client that if
he does not stay in bed, she will have to apply restraints
C. A family has conflicting feelings about the initiation of enteral
tube feedings for their father who is terminally ill
D. A client who is terminally ill hesitates to name their partner on
their durable power of attorney form - ANSWER- C
Rationale: making the decision about initiating enteral tube feedings is
an example of an ethical dilemma. A review of scientific data cannot
resolve the issue, and it is not easy to resolve. The decision will have a
profound effect on the situation and on the client.
Ch. 5) A nurse is discussing occurrences that require completion of an
, incident report with a newly licensed nurse. Which of the following
should the nurse include in the teaching (SATA)
A. Medication error
B. Needlesticks
C. Conflict with provider and nursing staff
D. Omission of prescription
E. Missed specimen collection of a prescribed laboratory test -
ANSWER- A, B, D
Rationale: complete an incident report regarding a medication error, a
needlestick, and omission of a prescription
Ch. 5) A nurse is receiving a provider's prescription by telephone for
morphine for a client who is reporting moderate to severe pain. Which
of the following nursing actions are appropriate? (SATA)
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the provider's signature on the prescription within 24 hours
D. Decline the verbal prescription because this is not an emergency
situation
E. Tell the charge nurse that the provider has prescribed morphine
by telephone - ANSWER- A, B, C Rationale:
A. The nurse should repeat the medications name, dosage, time or
interval, route, and any other pertinent information back to the provider
and receive and document confirmation
B. Having another nurse listen to the telephone prescription is a
safety precaution that helps prevent medication errors due to
miscommunication.
C. The provider must sign the prescription within the timeframe the
facility specifies in its policies generally 24 hours
Ch. 6) A nurse on a medical-surgical unit has received change-of-shift