Exam (elaborations)
Answer-Integrated Exam Saunders Nclex Ethical And Legal Issues 2024/2025
- Course
- Saunders NCLEX
- Institution
- Chamberlain School Of Nursing
Answer-Integrated Exam Saunders Nclex Ethical And Legal Issues 2024/2025
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Answer-Integrated Exam Saunders NclexEthical And Legal Issues 2024/2025
7.13. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and
finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, and
notifies the health care provider of the incident, and completes an incident report. What statement
should the nurse document on the incident report?
1. The client fell out of bed
2. The client climbed over the side rails
3. The client was found lying on the floor
4. The client became restless and tried to get out of bed Answer: Answer: 3
Rationale: The incident report should contain the client's name, age, and diagnosis. The report should
contain a factual description of the incident, any injuries experienced by those involved, and the
outcome of the situation. The correct option is the only one that describes the facts as observed by the
nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as
observed by the nurse.
Test-Taking Strategy: Focus on the subject, documentation of events, and read the information in the
question to select the correction option. Remember to focus on factual information when documenting
and avoid including interpretations. This will direct you to the correct option.
Reference: Huber (2013), p. 305-358 & Saunders p. 62.
7.14. A client is brought to the emergency department by emergency medical services (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?
1. Obtain a court order for the surgical procedure
2. Ask the EMS team to sign the informed consent
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family. Answer: Answer: 3
, Rationale: In general, there are two situations in which informed consent of an adult are not needed.
One is when an emergency is present and delaying treatment for the purpose of obtaining informed
consent would result in injury or death to the client. The second is when the client waives the right to
give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate.
Although option 4 may be pursued, it is not the best action.
Test-Taking Strategy: Note the strategic word best. Recalling that when an emergency is present and a
delay in treatment for the purpose of obtaining informed consent could result in injury or death will
direct you to the correct option.
Reference: Potter et al (2013), p. 302-303, Yoder-Wise (2011), p. 79-81, and Saunders p. 62.
7.15. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have
assessed the client and have determined that the client is not injured. After completing the incident
report, the nurse should implement which action next?
1. Reassess the client
2. Conduct a staff meeting to describe the fall
3. Document in nurse's notes that an incident report was completed
4. Contact the nursing supervisor to update information regarding the fall Answer: Answer: 1
Rationale: After a client's fall, the nurse must frequently reassess the client because potential
complications do not always appear immediately after the fall. The client's fall should be treated as
private information and shared on a "need to know" basis. Communication regarding the event should
involve only the individuals participating in the client's care. An incident report is a problem-solving
document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has
been made aware of the incident, the supervisor will contact the nurse if status update is necessary.
Test-Taking Strategy: Focus on the date in the question and the strategic word next. Using the steps of
the nursing process will direct you to the correct option. Remember that assessment is the first step.
Reference: Potter et al (2013), p. 358-371 & Sauders p. 62.
7.16. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day
because the ICU is understaffed and needs additional nurses to care for the clients. the nurse has never
worked in the ICU. The nurse should take which action first?
1. Call the hospital lawyer.
2. Refuse to float to the ICU.
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