A newly licensed nurse is preparing to insert an IV catheter in a client.

Which of the following sources is most important for the nurse to utilize
when reviewing the procedure and the standard at which it should be
performed?

Website
Offer general information but may not reflect the specific standards of the healthcare
facility where the nurse works.

Institutional policy and procedure manual

The institutional policy and procedure manual is the main resource because it provides specific
guidelines for tasks like inserting IV catheters. It details the protocols, best practices, and safety
standards the institution has established to ensure procedures are done correctly and safely.

More experienced nurse

A more experienced nurse can give guidance and practical tips, but they may not have
the exact written policies or procedures the nurse must follow.

State Nurse Practice Act

Outlines the legal framework for nursing and the scope of practice, but it does not
provide detailed procedural guidelines.
A client is brought to the emergency department by EMS after being hit
by a car. The name of the client is unknown, and the client has sustained
a severe head injury and multiple fractures and is unconscious. An
emergency craniotomy is required. Regarding informed consent for the
surgical procedure, which is the best action?

Obtain a court order for the surgical procedure

Getting a court order for surgery is usually not needed in urgent situations. Court orders
may be necessary if there is a dispute about consent, but that does not apply here.

Ask the EMS team to sign the informed consent

The EMS team cannot sign for informed consent. Only the patient (if possible) or a
legal representative can give informed consent.

Transport the victim to the operating room for surgery

In emergencies where a patient is unconscious, cannot give consent, and needs
immediate help to save their life or prevent more harm, we assume they would want the
necessary life-saving procedures. This is known as implied consent.

Call the police to identify the client and locate the family
It's important to identify the patient and contact their family, but this should not delay
life-saving surgery. The patient's life must come first, so we should not wait to identify
them or reach out to their family.
A nurse is caring for a client who has chest pain. The client says, “I am
going home immediately.” Which of the following actions should the
nurse take? (Select all that apply)

Notify the client’s family of their intent to leave the facility

While it can be helpful, informing the family is not mandatory and can wait unless
the client agrees or there’s an urgent need.

Document the client’s intent to leave the facility against medical advice
(AMA)
Record the client's decision to leave AMA to protect both the client and the facility,
ensuring it is noted in their medical record.

Explain to the client the risks involved if they choose to leave

Inform the client about the dangers of leaving without treatment, particularly in cases
like chest pain. Provide clear information while respecting their right to make their own
decisions.

Ask the client to sign a form relinquishing responsibility of the facility

While not legally required, it’s common to have the client sign a form acknowledging
the risks involved in leaving AMA.

Prevent the client form leaving the facility until the provider arrives
A competent adult cannot be stopped from leaving unless there’s a legal order in place.
The nurse should try to persuade the client to stay but cannot force them.
A nurse observes an assistive personnel (AP) reprimanding a client for
not using the urinal properly. The AP tells the client that diapers will be
used the next time the urinal is used improperly. Which of the following
torts is the AP Committing?

Assault
Assault occurs when someone intentionally makes another person feel afraid of harm or
unwanted contact, even without physical touch. The AP's statement about using diapers
could instill fear in the client regarding their dignity, which can be seen as a threat
causing emotional distress.

Battery
Battery involves actual harmful or offensive contact, and since the AP's words do not
imply physical contact, it doesn't qualify as battery

False imprisonment
False imprisonment is holding someone against their will, which doesn’t apply here as
there’s no evidence of physical restraint.

Invasion of privacy
Invasion of privacy concerns unauthorized access to personal information. While the
AP's reprimand may have impacted the client's dignity, it doesn’t meet the legal
definition of invasion of privacy.
A client who had stage IV pancreatic cancer decides to discontinue
treatment. Which of the following actions should the nurse take?

Offer alternative medications.

The nurse should be aware of other treatment options but should not suggest them if the
client has decided to stop. It's essential to first understand the client's reasons and any
unmet needs.
Encourage the client to reconsider.
Pressuring the client to change their mind can feel coercive. It's crucial to respect their
healthcare decisions, even if that means discontinuing treatment.
Ask the client to discuss the decision.
The nurse should have a caring conversation with the client about their desire to stop
treatment, understanding their reasons and addressing any emotional issues. It's vital
to respect the client's right to choose while providing support.
Request a mental health consultation.
Suggesting a mental health consultation may be appropriate if signs of depression or
anxiety are evident, but this should follow a discussion about the client’s feelings and
decision. Understanding their choice is the priority before any referrals.
 A client has a new diagnosis of stage IV lung cancer. When the partner
requests the diagnosis be withheld from the client, which of the
following actions should the nurse take?
Withhold the diagnosis from the client.
Nurses cannot conceal a diagnosis from a competent client without their consent. Clients
typically have the right to know their diagnoses, especially for serious conditions that
require treatment decisions, unless there are special circumstances, like a direct request
from the client.
Contact the institution's ethics committee.
This step can be considered if there is a conflict between the client’s right to know and the
family’s wishes, but it should follow discussions with the partner and healthcare team.
Document the request in the medical record.
The nurse should note the partner’s wish to keep the diagnosis from the client, which
serves to protect the nurse legally and supports future discussions regarding the client’s
care.
Request additional information from the partner.
After documenting the request, the nurse can discuss the partner’s concerns to clarify
their reasons, but withholding the diagnosis is not appropriate without specific
circumstances.
The nurse who works on the night shift enters the medication room and
finds a coworker with a tourniquet wrapped around the upper arm. The
coworker is about to insert a needle, attached to a syringe containing a
clear liquid, into the antecubital area. Which is the most appropriate
action by the nurse?

Call security
If the situation escalates, contact security after notifying the nursing supervisor, who is
best equipped to handle the issue.

Call the police

Call the police if there’s clear evidence of illegal activity, but first report to the nursing
supervisor, who will decide on police involvement.

Call the nursing supervisor

There is a serious concern about a coworker possibly misusing drugs, as they appear to be
preparing for intravenous use. This violates workplace rules and could be illegal. The
nurse should inform the supervisor immediately for investigation and safety.

Lock the coworker in the medication room until help is obtained

This could violate their rights and worsen the situation. Proper channels should be
followed to address the issue.
An older client is brought to the emergency department for treatment of
a fractured arm. On physical assessment, the nurse notes old and new
ecchymotic areas on the client’s chest and legs and asks the client how the
bruises were sustained. The client, although reluctant, tells the nurse in
confidence that a family member frequently hits the client if supper is
not prepared on time when the family member arrives home from work.
The nurse plans to make which most appropriate response?

“Oh really? I will discuss this situation with your family member”
This is inappropriate as it risks the client's safety, breaches confidentiality, and may
lead to retaliation from the abuser.

“Let’s talk about the ways you can mange your time to prevent this from
happening”
This response mistakenly shifts blame to the client and downplays the seriousness of the
abuse.

“Do you have any friends who can help you out until you resolve these
important issues with your family member?”
This minimizes the abuse's severity and suggests informal solutions instead of
prioritizing the client's safety and necessary reporting.

“As a nurse, I am legally bound to report abuse. I will stay with you while you
give the report and help find a safe place for you to stay.”
Nurses must report suspected abuse, particularly for vulnerable individuals like older
adults. If a client reports being harmed by a family member, the nurse must alert
authorities like Adult Protective Services to ensure the client's safety.
A nurse manager is providing information to the nurses on the unit
about ensuring client rights. Which of the following regulations outlines
the rights of individuals in healthcare settings?

American Nurses Association Code of Ethics

A professional guide for nurses that emphasizes ethical responsibilities to promote health
and provide safe care, but does not specifically outline patient rights.

HIPAA
A federal law that protects the privacy and security of patients' health information,
ensuring confidentiality of medical records, though it does not cover all patient rights.

Patient Self-Determination Act

This law mandates healthcare providers to inform patients about their rights in
decision-making and advance directives, focusing on patient autonomy rather than the
full spectrum of patient rights.

Patient Care Partnership

This document outlines patients' rights and responsibilities in healthcare settings,
including expectations for care, privacy, informed consent, and decision-making,
ensuring respect and dignity.