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A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? Justice Fidelity Nonmaleficence Autonomy Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Focus on the subject - the ethical principle being utilized. Recall the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review: principles of healthcare ethics. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment
Question 1
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Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Celluar Regulation, Ethics HESI Concepts: Advocacy/Ethical/Legal Issues, Cellular Regulation
Question 2
HESI Concepts: Advocacy/Ethical/Legal Issues, Immunity The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right?
Question 3
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Threatening to give a client a medication against his or her will Telling the client that he or she may not leave the hospital Observing the provision of care to the client without the client’s permission Performing a procedure without consent Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment_._ Note the relationship of the subject and the words in the correct option. Review: the concept of false imprisonment. References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., pp. 175, 176). St. Louis: Mosby. Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p. 424). Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Giddens Concepts: Health Care Law, Leadership HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care Law The nurse and an unlicensed assistive personnel (UAP)enter a client’s room to
Question 4
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Contact the unit secretary on the intercom and ask that the client’s health care provider be called Check the client’s level of consciousness and vital signs Ask the nursing assistant to complete an incident report Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the UAP to assist in getting the client into bed. The nurse should then contact the health care provider and file an incident report. Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review: client injuries and procedures for filing incident reports. References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient– centered collaborative care (6th ed., p. 180). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Mobility, Safety HESI Concepts: Mobility, Safety Which action exemplifies the use of evidence-based practice in the delivery of
Question 5
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client care? Taking a rectal temperature from a client for whom bleeding precautions have been instituted Encouraging a client to take an herbal substance to treat his insomnia
Prescribing treatments specific to the client’s needs Coordinating consultations and referrals to facilitate discharge
Assessing the client’s needs for home supplies and equipment Evaluating and updating the plan of care as needed Establishing a safe and cost-effective plan of care with the client Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review: the responsibilities of the case manager if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 21). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area:
The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option.
Review: the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management
Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Giddens Concepts: Ethics, Health Care Policy HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care Policy
The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? Tape the wedding band in place Ask the client whether she would like to remove the wedding band or wear it to surgery Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery Explain to the client why the wedding band must be removed Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. Test-Taking Strategy: Focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review: preoperative procedures for a client’s valuables. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby.
Question 9
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The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? Telling the client that the medal and chain will be kept at the nurses’ station for safekeeping while the client is undergoing the x-ray Asking the client to remove the medal until the x-ray has been completed Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department Rationale: A client undergoing a chest x-ray must remove all metal objects to help prevent artifacts on the x-ray. If the client expresses concern about removing the medal, the nurse should help the client pin the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. The nurse should also alert staff in the radiology department that this has been done. If the client is expressing concern about removing the medal, asking the client to remove it or leave it with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the likelihood that the medal and chain will be lost. Test-Taking Strategy: Note that the client is expressing concern about removing the religious medal. Eliminate the options that are comparable or alike in that they indicate that the client should remove the medal. Also note that the correct option is the only option that addresses the client’s concern. Review: care of clients’ valuables
Question 10
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Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety
