For correct answer choice:

Notifying the surgeon to obtain consent before surgery is correct. Consent is a legal requirement, and it must be secured prior to any surgical procedure. The nurse's priority is to ensure that the surgeon addresses this critical issue before the patient is transported to the operating room.

For incorrect answer choices:

Instruct the patient about the medication effects is incorrect. While it is important for the nurse to inform the patient about the effects of preoperative medication, it is secondary to the need for a signed consent form. The consent must be secured before any other discussions related to the procedure can take place.

Prepare the patient for transport to the operating room is incorrect. This action is premature if the consent has not been signed. The nurse must first address the consent issue to prevent any legal complications before proceeding with transport preparations.

Document the administration of the medication and the situation is incorrect. Although documentation is necessary for accurate medical records, it is not the priority action. Addressing the consent form is essential to prevent any legal or ethical concerns regarding the surgery.

Correct:

Amlodipine 5 mg PO daily. QD and QOD can be mistaken for each other when handwritten.

MS could be taken for morphine sulfate or magnesium sulfate. There was no time frequency given as well.

Dulcolax supp 10 mg rectally every other day is the correct documentation. QOD can be mistaken when written for QD or O for and I.

LEARNING OBJECTIVE

Nurses and other health professionals must utilize correct medical terminology during documentation to avoid dangerous abbreviations, especially regarding medication administration. The Joint Commission has an Official “Do Not Use” List to eliminate such abbreviations. This list aims to reduce errors. As a nurse, you must know which abbreviations are or are not permissible, according to the Joint Commission, State Board, or your workplace.

Correct: While one child is ready to follow their parent’s wishes, the other is not. Thus creating a dilemma. This case should be referred so the patient’s wishes can be followed and the children’s issues can be resolved.

Incorrect: While these three situations all involve various levels of savvy to handle, they do not warrant a referral to the ethics committee. The preop patient may need some further counseling other than the bedside nurse to complete a living will and power of attorney paperwork. Hence, a referral to social work or case management may be required. The children who are fighting over the funeral home may need counseling during the dying process. They may also need social work, a case manager, or even hospice as a referral. The family of the patient with a head injury has made a reasonable request and seems to be coping. However, they may need help coping in the future.

LEARNING OBJECTIVE

Nurses become involved in their patient’s life as well as their families. Being a patient advocate is essential to nursing. A resolution can be worked on promptly by swiftly recognizing an ethical dilemma. The goal is to do the best for your patient by following their wishes.

For correct answer choice:

Administer prescribed medications and monitor for therapeutic effects is correct. This task falls within the scope of practice for an LPN, who is qualified to administer medications and observe their therapeutic and adverse effects, making it an appropriate task for delegation in a memory care setting.

For incorrect answer choices:

Create educational materials for families about dementia care is incorrect. Developing educational materials requires comprehensive knowledge about dementia care and should be done by an RN, who can ensure that the information provided is accurate, evidence-based, and covers all necessary aspects of care.

Evaluate the effectiveness of the current care plan for each resident is incorrect. This task involves assessing the residents’ responses to the care plan and making necessary adjustments, which requires critical thinking and clinical judgment, tasks that are typically within the RN's responsibilities.

Implement behavior management strategies for challenging behaviors is incorrect. Although LPNs may assist in managing resident behaviors, the development and oversight of behavior management strategies require an RN’s expertise to assess individual resident needs and provide appropriate interventions.

Correct: The patient cannot undergo his procedure without consent. Part of informed consent is being educated on his procedure. Nurses can help educate and review understanding with the patient. Ultimately, the physician is responsible for verifying understanding of the procedure and the potential for complications before the consent is signed. Nurses should educate patients on post-op care so that they know what to expect upon awakening from their procedure.

Incorrect: While including the patient in discharge planning is essential, the patient has not yet had surgery. Some patients may need inpatient therapy, while others may be able to go home with physical therapy. Physical therapy options for discharge should be reviewed after post-up evaluations are completed.

LEARNING OBJECTIVE

Besides following the preop orders of the physician, educating the patient on his procedure and post-op care is essential. Patients should understand their procedure and know what to expect following it to enhance their recovery process.

The Correct answer is: The student should explain that she cannot but offer to help with the emergency or ask her instructor or another nurse to hang the PRBCs. Learning to manage the care of patients effectively is crucial to being a nurse. The best solution is to find someone who can legally complete the task or offer her assistance with the emergency if acceptable.

Incorrect: The student should refuse. The student did not explain or help the nurse by refusing to complete the task.

The student should hang the PRBCs if the nurse does not tell anyone, as she has already been trained on the protocol. By not following the board's rules as a student, the BON could elect not to allow the student to apply for licensure.

The student should explain that the Board of Nursing (BON) regulations prohibit her from performing the task. It is essential to explain why you cannot perform a task. However, learning to find solutions is vital to managing multiple patients.

LEARNING OBJECTIVE

As both a nursing student and a nurse, it is essential to know the rules and regulations of the BON in the state in which you practice. Failure to follow such regulations can result in action against your nursing license, or the board may prohibit you from obtaining a nursing license based on your actions as a student.

For correct answer choice:

Administer diuretics as prescribed to reduce fluid overload is correct. Diuretics are the first-line treatment for fluid overload, which contributes to the patient’s acute dyspnea, edema, and elevated jugular venous distention. Administering diuretics will help reduce fluid retention, thereby improving respiratory function and relieving symptoms.

For incorrect answer choices:

Order a chest X-ray to evaluate for pulmonary congestion is incorrect. While imaging is important for diagnosing the extent of pulmonary congestion, it does not provide immediate relief from the acute symptoms the patient is experiencing.

Initiate continuous cardiac monitoring for arrhythmias is incorrect. Although cardiac monitoring is important for patients with congestive heart failure, it is not the immediate priority since it does not address the patient’s respiratory distress or fluid overload.

Elevate the head of the bed to facilitate easier breathing is incorrect. Elevating the head of the bed can improve breathing by reducing pressure on the lungs, but it does not treat the root cause of the dyspnea, which is fluid overload. Administering diuretics is a more direct intervention to relieve the symptoms.

Correct: Relevant

Incorrect: S-Specific, M-Measurable, A-Achievable, R-Relevant, and T-Time-bound are the SMART goal format.

LEARNING OBJECTIVE

Critical thinking is an essential nursing skill. Learning to act fast is crucial in emergencies. However, nurses must learn to recognize when improvements are needed. Thus, quality improvement lays out a process to identify a problem, gather data, develop and implement an intervention, and evaluate the results. The goal is first to recognize and improve to optimize the care of your patients.

Correct: Post-op open heart surgery patient with new-onset afib and shortness of breath. Any patient with new symptoms and those impacting the ABCs (airway, breathing, and circulation) should be seen first.

Incorrect:

Post-op open heart surgery patient anxious for discharge standing at his door. Although this patient is anxious to leave the hospital, he can, unfortunately, wait. You can ask someone to politely tell him an estimated time for you to review his discharge instructions.

Post-op open heart surgery patient complaining of pain 5 out of 10. Since this patient is complaining of pain and is post-op, he should be seen next to verify the pain is related to incision and not new.

Post-op open heart surgery patient complaining of gas. This patient should be seen next to verify his symptoms and when he last had a bowel movement.

LEARNING OBJECTIVE

Nurses must learn to prioritize the care of their patients by learning who to evaluate first. When caring for multiple patients, managing time and patient needs is vital to planning the day. When unexpected emergencies arise, utilizing resources to optimize care is crucial.

For correct answer choice:

A 29-year-old female presenting with severe chest pain and difficulty breathing after a recent viral infection is correct. This patient may be facing a serious condition like a pulmonary embolism or myocarditis, which can occur after a viral infection. It's essential to conduct an immediate assessment to determine if there are any serious issues with their heart or lungs that need attention.

For incorrect answer choices:

A 50-year-old male scheduled for a colonoscopy in 2 hours who needs to be prepped for the procedure is incorrect. While prepping for the procedure is necessary, this patient is stable and does not require immediate intervention compared to the patient with severe chest pain and respiratory distress.

A 68-year-old female with a history of congestive heart failure who is awaiting an echocardiogram is incorrect. Although this patient needs monitoring, the patient presenting with acute chest pain and difficulty breathing has more urgent, potentially life-threatening symptoms that require priority assessment.

A 40-year-old male with a fractured wrist requiring pain management prior to discharge is incorrect. While pain management is important, this patient’s condition is stable and does not require immediate intervention compared to the patient with chest pain and respiratory issues.

Correct:

First, you must stop and address your nurse with signs and symptoms of hypoglycemia. When blood sugar drops from insulin injections without food intake, especially in a stressful environment, a nurse may not even recognize her symptoms. T

he next thing is to call for more assistance. Whether some nurses from administration or other floors briefly come to assist, the staff need a break to eat and just sit.

Incorrect:

The staff does need your assistance; however, they do not need a sick nurse. They also need a break.

Asking the secretary to get orange juice is a good idea. However, another nurse needs to assess her signs of hypoglycemia. The secretary is not equipped to assess hypoglycemia and a patient’s status.

LEARNING OBJECTIVE

Whether a manager or a nurse, when limitations of resources occur, you must be able to recognize the situation and react. Sometimes, it may take some time to recognize the need for further assistance. Once you react, utilize resources and do your best to care for your patients.

For correct answer choice:

Autonomy is correct. It refers to the patient’s right to make informed decisions about their own healthcare, including the right to refuse treatment. The patient's refusal of medication clearly reflects their exercise of autonomy and self-determination regarding their health choices.

For incorrect answer choices:

Informed consent is incorrect. While informed consent involves providing patients with information about the risks and benefits of treatment options, it does not specifically address the right of a patient to refuse treatment, which is a key aspect of autonomy.

Civil liability is incorrect. Civil liability refers to legal responsibility for actions that cause harm to another party. In this situation, the patient's refusal to take medication does not relate to actions that would create liability; rather, it is about their right to make healthcare decisions.

Statutory regulation is incorrect. Statutory regulation involves laws enacted by a legislative body governing specific practices. The patient's refusal to take medication is not a matter of statutory regulation, but rather a matter of personal choice and autonomy.

Correct: The abdomen is flat, symmetric, soft, and non-tender to palpation in all four quadrants. Bowel sounds are present in all four quadrants. No masses or organomegaly were palpated in all four quadrants.

Incorrec: The abdomen is flat, symmetric, soft, and non-tender to palpation. Bowel sounds present. No masses were palpated, or organomegaly palpated. Handwritten documentation should be specific and document all four quadrants. Thus, the statement clearly states where the examiner performed the assessment.

No abnormal findings and Normal abdominal assessment: Both are vague when writing a handwritten assessment. The documentation should be clear and concise as to what was assessed.

LEARNING OBJECTIVE

While most facilities have electronic documentation, nurses must know the correct documentation. The nurse must correctly document the assessment, whether electronically or by hand. It is crucial when noting changes in a patient’s condition. Years later, the records may also be reviewed for legal purposes. The nurse will need correct documentation to recall her assessment findings.

Correct: During nurse hand-off, date of admission, allergies, and code status are vital information.

Incorrect: While sharing that the patient has seven children may be pertinent, providing all seven names is not. Sharing the name of the family spokesperson or person handling advance directives is however vital to nurse hand-off.

LEARNING OBJECTIVE

Each unit or facility may desire key components to share patient information during hand-off. It is critical to share basic information. The Joint Commission has provided resources to protect patient safety.

For correct answer choice:

Initiate oxygen therapy to maintain SpO₂ above 92% is correct. In a patient with COPD experiencing increased shortness of breath, ensuring adequate oxygenation is the priority. Initiating oxygen therapy immediately helps stabilize the patient's oxygen levels, reducing the risk of hypoxemia and further respiratory distress.

For incorrect answer choices:

Assess lung sounds and respiratory rate is incorrect. Although assessing respiratory status is important, it does not directly intervene in correcting the patient's current oxygenation problem. Stabilizing the patient’s oxygen levels should take precedence.

Administer prescribed bronchodilator medications is incorrect. Bronchodilators are essential for managing COPD symptoms, but oxygen therapy should be initiated first to address the immediate need for improved oxygenation.

Encourage the patient to use incentive spirometry is incorrect. While incentive spirometry aids in lung expansion and long-term respiratory function, it does not address the acute need for oxygenation, making it a lower priority in this situation.

For correct answer choice:

Assist the patient with activities of daily living, such as bathing and dressing is correct. These tasks fall within the nursing assistant’s scope of practice and help support the patient's comfort and independence without requiring clinical judgment, making it an appropriate delegation.

For incorrect answer choices:

Perform a comprehensive assessment of the patient's respiratory status is incorrect. Comprehensive assessments require the clinical expertise of a registered nurse (RN), as they involve interpreting data and making clinical judgments, which are beyond the scope of a nursing assistant’s role.

Instruct the patient on the proper use of a peak flow meter is incorrect. Education and patient teaching are the responsibilities of the RN, as they require detailed knowledge and the ability to ensure the patient understands and correctly implements the instructions.

Monitor the patient’s oxygen saturation levels continuously during the shift is incorrect. While a nursing assistant can take basic vital signs, continuous monitoring requires close attention and the ability to recognize and respond to changes, which falls under the RN's scope of practice.

Correct: The patient is now showing both physical and emotional signs of abuse. He is losing weight and has bruising in multiple areas. Emotionally, he will not speak to you or allow you to touch him, acting withdrawn.

Incorrect: If his health was deteriorating, other diagnoses would substantiate it.

There is no dementia diagnosis. Until this visit, the patient had been smiling, and no other bruising had been reported.

LEARNING OBJECTIVE

Nurses must not only recognize abuse but are mandated to report it. Although his increased ER visits and hospitalizations went unnoticed as a sign, the bruising and his behavior point toward abuse. He needs to be tenderly questioned and examined as a victim of abuse.