Question

A nurse manager is reviewing recent incidents on the unit. Which of the following events should the nurse manager identify as requiring a root cause analysis (RCA)?

Answer 1

Correct Answers:

A client dies due to a medication error

Rationale :

⏩ A root cause analysis is a structured process used after a serious safety event to determine the underlying system factors that contributed to the outcome.

⏩ A medication error that results in a client's death represents a serious reportable event and requires comprehensive investigation beyond identifying the individual who made the error.

⏩ The RCA examines contributing factors such as medication processes, staffing, communication, technology, policies, environmental conditions, and workflow.

⏩ The goal is to identify system vulnerabilities and implement changes that reduce the likelihood of the same error occurring again.

⏩ A client death resulting from a medication error therefore clearly warrants a formal root cause analysis and corrective action plan.

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Answer 2

Correct Answers:

Integrity
Altruism
Autonomy
Social Justice

Rationale :

Integrity

✅ Integrity means consistently acting according to ethical and professional standards, even when no one is observing.

✅ Nurses demonstrate integrity by being truthful, maintaining confidentiality, documenting accurately, and accepting responsibility for their actions.

✅ Integrity supports trust between nurses, clients, families, and healthcare professionals.

✅ A nurse with integrity does not falsify information or conceal errors and instead follows professional standards of accountability.

✅ Integrity is therefore a fundamental professional nursing value.

Altruism

✅ Altruism refers to concern for the welfare and well-being of others.

✅ Nurses demonstrate altruism by advocating for clients, protecting vulnerable individuals, and placing appropriate client needs above personal convenience.

✅ This value supports compassionate, respectful, and service-oriented nursing practice.

✅ Altruism does not mean ignoring professional boundaries but rather acting to promote the client's best interests.

✅ Altruism is therefore recognized as an important professional nursing value.

Autonomy

✅ Autonomy reflects respect for a person's right to make informed decisions about their own healthcare.

✅ Nurses promote autonomy by providing accurate information, respecting treatment refusals, and supporting informed consent.

✅ The nurse should avoid coercing clients or making healthcare decisions solely on the client's behalf when the client has decision-making capacity.

✅ Respect for autonomy protects the client's self-determination, dignity, and control over personal healthcare choices.

✅ Autonomy is therefore an important professional value guiding nursing practice.

Social Justice

✅ Social justice involves promoting fairness and equitable access to healthcare resources and opportunities.

✅ Nurses demonstrate social justice by advocating for clients who experience poverty, discrimination, disability, or limited access to healthcare.

✅ The value encourages nurses to recognize and address health disparities and unequal treatment.

✅ Social justice also supports fair allocation of resources and respect for the rights of all individuals and populations.

✅ It is therefore a core professional nursing value.

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Answer 3

Correct Answers:

Initiate cardiopulmonary resuscitation (CPR) and activate the emergency response system.

Rationale :

➡️ A DNR order must be formally authorized and documented according to legal and institutional requirements before resuscitation can be withheld.

➡️ A family's request for DNR status does not by itself constitute an active medical order directing staff to withhold CPR.

➡️ Because the client is pulseless and no valid DNR order is currently documented, the nurse must treat the client as full code.

➡️ CPR and emergency response activation should begin immediately because delays reduce the likelihood of successful resuscitation.

➡️ The nurse should therefore initiate CPR while the healthcare team clarifies the client's code status and existing goals-of-care documentation.

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Answer 4

Correct Answers:

"Information about a client can be disclosed to family members at any time."

Rationale :

↪️ HIPAA protects individually identifiable health information and limits disclosure to authorized individuals and permitted purposes.

↪️ Family members do not automatically have unrestricted access to a client's private health information simply because they are related to the client.

↪️ The nurse should verify the client's permission, legal authority, or another applicable HIPAA exception before sharing protected information.

↪️ Disclosure should also follow the minimum necessary principle, meaning only information required for the intended purpose should be shared.

↪️ This statement therefore indicates a misunderstanding of confidentiality and requires additional instruction.

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Answer 5

Correct Answers:

The client seems to be more comfortable performing self-administration of insulin.

Rationale :

*️⃣ Documentation should be objective, specific, measurable, and factual rather than based on vague interpretations.

*️⃣ The word “seems” reflects the nurse's subjective impression and does not clearly describe what the client actually did or said.

*️⃣ A stronger entry would document observable behavior, such as the client independently preparing and administering insulin with correct technique.

*️⃣ Precise documentation improves communication between healthcare professionals and provides a more defensible legal record of care.

*️⃣ This entry therefore requires revision because it uses unclear and interpretive language rather than objective evidence.

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Answer 6

Correct Answers:

Supporting a client's wishes to refuse prescribed treatments

Rationale :

💠 Autonomy means respecting a competent client's right to make informed decisions about personal healthcare.

💠 The right to make decisions includes the right to refuse medications, procedures, or other treatments, even when healthcare professionals recommend them.

💠 The nurse should ensure that the client has relevant information about risks, benefits, and alternatives without using coercion.

💠 The client's refusal should be documented and communicated to the appropriate healthcare provider while the client's decision is respected.

💠 Supporting a client's informed refusal therefore directly demonstrates respect for autonomy.

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Answer 7

Correct Answers:

Implement teamwork and communication training to prevent future errors.
Encourage staff to report near-misses and errors without fear of punishment.
Conduct a non-punitive investigation to understand system factors contributing to the error.

Rationale :

Implement teamwork and communication training to prevent future errors.

❇️ A just culture seeks to identify system problems that contribute to errors rather than automatically blaming one individual.

❇️ Because communication breakdown contributed to the medication error, targeted teamwork and communication training directly addresses an identified risk factor.

❇️ Standardized handoff tools, closed-loop communication, and team training can reduce information loss and prevent future errors.

❇️ Corrective actions should address both individual practice needs and system-level vulnerabilities.

❇️ Implementing communication training is therefore consistent with a just-culture approach to prevention.

Encourage staff to report near-misses and errors without fear of punishment.

❇️ Staff are more likely to report errors when they believe the organization will respond fairly rather than automatically punish them.

❇️ Increased reporting provides valuable information about unsafe processes before they result in serious client harm.

❇️ A just culture differentiates human error from reckless behavior and responds appropriately to each situation.

❇️ Psychological safety promotes transparency, organizational learning, and continuous quality improvement.

❇️ Encouraging reporting without fear therefore strengthens the healthcare organization's safety culture.

Conduct a non-punitive investigation to understand system factors contributing to the error.

❇️ A non-punitive investigation examines staffing, workload, communication, policies, equipment, and workflow that may have contributed to the error.

❇️ The fact that understaffing and communication failures were involved indicates that system-level factors need careful evaluation.

❇️ Investigation should distinguish unintended human error from risky choices or reckless conduct rather than assuming all errors deserve punishment.

❇️ Understanding the underlying causes allows leaders to develop interventions that prevent similar events throughout the organization.

❇️ A fair systems-focused review is therefore central to the principles of just culture.

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Answer 8

Correct Answers:

Place a surgical mask on the client when they leave their room.

Rationale :

⏭️ Droplet precautions are used for infections transmitted through large respiratory droplets generated by coughing, sneezing, or speaking.

⏭️ When transport outside the room is medically necessary, the client should wear a surgical mask to reduce dissemination of infectious respiratory secretions.

⏭️ Transport should be limited to essential purposes, and receiving departments should be informed of the required precautions.

⏭️ Healthcare personnel should also use appropriate masking and standard precautions according to the organism and facility policy.

⏭️ Placing a surgical mask on the client during transport is therefore the appropriate infection-control action.

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Answer 9

Correct Answers:

Prescription received for MSO4 4.0 mg PRN pain

Rationale :

🔼 The abbreviation “MSO4” is unsafe because it can be confused with MgSO4, which represents magnesium sulfate.

🔼 Medication names such as morphine sulfate should be written out completely to reduce the risk of medication error.

🔼 The dose “4.0 mg” also contains a trailing zero, which can be misread as 40 mg if the decimal point is missed.

🔼 Safe documentation would state morphine sulfate 4 mg PRN pain using approved terminology and no trailing zero.

🔼 This entry therefore contains two high-risk documentation practices and requires immediate correction.

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Answer 10

Correct Answers:

Ask a nurse to supervise while performing the sterile dressing change.

Rationale :

💟 Nursing students should perform procedures only when they have appropriate education, preparation, supervision, and demonstrated competency.

💟 Asking a licensed nurse to supervise protects the client while allowing the student to practice and develop clinical competence.

💟 The supervising nurse can guide sterile technique, identify breaks in sterility, and intervene if safety concerns arise.

💟 Recognizing personal limitations is an important component of professional accountability and safe nursing practice.

💟 Requesting appropriate supervision therefore best balances client safety with the student's educational needs.

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QLexNursing

1 :
A nurse manager is reviewing recent incidents on the unit. Which of the following events should the nurse manager identify as requiring a root cause analysis (RCA)?

2 :
A nurse is reinforcing teaching about professional values in nursing to a newly licensed nurse. Which of the following information should the nurse include (Select All that Apply.)

3 :
A nurse enters a client's room and finds the client pulseless. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. Which of the following actions should the nurse take?

4 :
A nurse is reviewing HIPAA with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further instruction?

5 :
A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

6 :
A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

7 :
A nurse manager discovers that a medication error occurred on the unit due to understaffing and communication breakdown. In applying the principles of just culture, which actions should the nurse manager take to promote accountability and a safe environment? (Select All that Apply.)

8 :
A nurse is assisting with the care of a client who is placed on droplet precautions. Which of the following actions should the nurse take?

9 :
A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

10 :
A nursing student is assigned to perform a sterile dressing change but feels uncomfortable performing the skill independently. Which action should the student take?

QLexNursing

1 : A nurse manager is reviewing recent incidents on the unit. Which of the following events should the nurse manager identify as requiring a root cause analysis (RCA)?

2 : A nurse is reinforcing teaching about professional values in nursing to a newly licensed nurse. Which of the following information should the nurse include (Select All that Apply.)

3 : A nurse enters a client's room and finds the client pulseless. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. Which of the following actions should the nurse take?

4 : A nurse is reviewing HIPAA with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further instruction?

5 : A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

6 : A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

7 : A nurse manager discovers that a medication error occurred on the unit due to understaffing and communication breakdown. In applying the principles of just culture, which actions should the nurse manager take to promote accountability and a safe environment? (Select All that Apply.)

8 : A nurse is assisting with the care of a client who is placed on droplet precautions. Which of the following actions should the nurse take?

9 : A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

10 : A nursing student is assigned to perform a sterile dressing change but feels uncomfortable performing the skill independently. Which action should the student take?

1 :
A nurse manager is reviewing recent incidents on the unit. Which of the following events should the nurse manager identify as requiring a root cause analysis (RCA)?

2 :
A nurse is reinforcing teaching about professional values in nursing to a newly licensed nurse. Which of the following information should the nurse include (Select All that Apply.)

3 :
A nurse enters a client's room and finds the client pulseless. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. Which of the following actions should the nurse take?

4 :
A nurse is reviewing HIPAA with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further instruction?

5 :
A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

6 :
A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

7 :
A nurse manager discovers that a medication error occurred on the unit due to understaffing and communication breakdown. In applying the principles of just culture, which actions should the nurse manager take to promote accountability and a safe environment? (Select All that Apply.)

8 :
A nurse is assisting with the care of a client who is placed on droplet precautions. Which of the following actions should the nurse take?

9 :
A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

10 :
A nursing student is assigned to perform a sterile dressing change but feels uncomfortable performing the skill independently. Which action should the student take?