Final exams study set for Leadership hesi

A nurse is presenting an in-service about delegation to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

"Delegation permits a designated individual to meet a goal on your behalf."

A nurse is teaching a newly licensed nurse about actions to take to ensure the confidentiality of a client's computerized medical record. Which of the following instructions should the nurse include?

"Do not allow others to see client information on your computer screen."

A nurse assigned a task to an assistive personnel (AP) who did not perform the task within the predetermined timeframe. Which of the following statements should the nurse make to the AP?

"I need you to tell me why you did not complete your assigned task."

A nurse is planning discharge for a client who has cirrhosis and experienced ascites and esophageal varices during hospitalization. The nurse should collaborate with which of the following members of the interdisciplinary team to perform specialized care for this client?

A dietitian to teach about a low-sodium diet

A nurse on a medical-surgical unit is deciding which clients can be discharged to make beds available for injured clients following a mass casualty event. Which of the following clients should the nurse recommend for discharge?

A young adult client who has Crohn's disease and is scheduled for an ileostomy in 24 hr

Which procedure is most often consented to with an implied client consent?

Administration of an intramuscular injection

A nurse is caring for a group of clients. Which of the following clients should the nurse assess first?

C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

A patient diagnosed with AIDS asks about the possibility of using hospice. In order to be eligible for hospice care, the patient must:

C. Have a life expectancy of less than six months

The nurse is caring for a client with severe pain. The order in the chart reads "Give MSO4 10 mg for pain." The first action the nurse should take is:

Call the prescribing healthcare provider

A nurse begins rounds on assigned clients on the 7 a.m. to 7 p.m. shift and finds a used needle in a client's room that was not properly disposed of after medication administration the previous shift. Which of the following is the most appropriate immediate response?

D. The nurse should dispose of the needle in the sharps container.

A nurse on an oncology unit accidently administered doxorubicin to the wrong client, resulting in harm to the client. This action is an example of which of the following torts?

Malpractice

A nurse is delegating client care to a team of staff members. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Obtain a scheduled blood glucose reading from a client.

Which client right is MOST similar to autonomy?

Self-determination

A nurse is caring for a client who had a stroke 3 days ago and has developed dysphagia. The nurse should identify that a referral to which of the following members of the interdisciplinary team is the priority?

Speech therapist

A nurse knows that order "read back" must be done for which of the following?

When a verbal order is taken

A nurse accuses a newly licensed nurse of providing inadequate care for a client who underwent hip arthroplasty. Which of the following responses by the newly licensed nurse demonstrates assertiveness?

"I feel as though I met the standard of care. Would you tell me more about your concerns?"

A nurse manager is investigating reports from nurses who report a staff nurse on the previous shift frequently leaves tasks uncompleted. The nurse manager notes that the staff nurse delegates an unfair share of tasks to the assistive personnel (AP). Which of the following statements should the nurse manager make to the staff nurse?

"I need to talk to you about unit expectations regarding delegating and completing tasks."

A nurse is caring for a client who has terminal lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client should indicate to the nurse that the client understands hospice care?

"I should expect the hospice team to help me manage my difficulty breathing."

A nurse is preparing to contact a provider regarding a client. When using the SBAR communication tool, which of the following statements should the nurse include in the B step?

"The client was found unconscious on the floor in her home."

A nurse is providing discharge teaching about medications to a client who has a low level of health literacy. Which statement indicates that the nurse is accounting for this client's level of health literacy?

"This medication can make you feel dizzy because it will lower your blood pressure."

A charge nurse in a pediatric unit is providing a room assignment for a child who is postoperative following an appendectomy. The charge nurse should place the postoperative child with which of the following clients?

A child who has a new diagnosis of type 1 diabetes mellitus

A nurse is assigned four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

A client who has a cast on the left leg and reports numbness and paresthesia

A nurse is presenting an in-service on legal issues affecting nurses. Which of the following situations should the nurse include in the teaching as an example of malpractice?

A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.

A nurse is providing teaching to a client who has been newly diagnosed with schizophrenia and is being discharged from an inpatient facility. Which of the following community resources should the nurse include for continued mental health care?

A. Partial hospitalization program

A nurse on a mental health unit is assigning tasks to an unlicensed assistive personnel (UAP). Which of the following tasks should the nurse assign to the AP? (Select all that apply.)

Accompany a client who has depression to individual therapy. Check the position of a client in soft wrist restraints. Sit with a newly admitted client who has alcohol use disorder.

Goals of case management in the hospital setting include:

Acting as a client advocate to ensure that clients receive needed services and education Monitoring and intervening as needed to ensure that the desired goals and outcomes are achieved for both the clients and the facility Transitioning of clients to the appropriate level of care Coordination of services/multidisciplinary coordination to ensure that clients receives the care they require

A nurse manager is reviewing the admission history of four adult clients. The nurse is required to report which of the following situations to an outside agency?

An older adult client who is dependent on caregivers and was admitted for the treatment of burns on the buttocks Rationale: Older adult abuse can occur in the form of neglect or as physical, emotional, or financial abuse. The nurse should assess the older adult client for manifestations of physical or behavioral abuse. Manifestations of neglect can include pressure sores, dehydration, malnutrition, contractures, body odor, and lethargy. Physical manifestations of older adult abuse can include burns to the buttocks and soles of the feet, vaginal and anal bruises, skeletal fractures, welts, lacerations, and bruises at different stages of healing. Threats, humiliation, intimidation, and isolation are examples of emotional abuse. Financial abuse involves unauthorized or improper use of the older adult's finances. The nurse should assess the behavior of the older adult client for manifestations of abuse, such as anger, aggression, depression, physical or cognitive impairment, listlessness, and withdrawal. Nurses are responsible for reporting suspicion of older adult abuse to the local Adult Protective Services agency.

A staff nurse asks an assistive personnel (AP) to ambulate a client and the AP refuses. Which of the following actions should the nurse take?

Ask the AP about her concerns with the assignment.

A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks should the nurse assign to the LPN?

Change the negative pressure wound therapy dressing on a client's chronic wound

The unit secretary is transcribing a healthcare provider's written order and asks the nurse to interpret an illegible phrase. Which of the following is the most appropriate action by the nurse in response?

Clarify the order by calling the healthcare provider

A nurse who applies for a transfer to another unit is told by that unit's nurse manager that a position would be made available if the nurse agrees to date the nurse manager. Which of the following actions should the nurse take?

Clearly tell the nurse manager that the proposal causes discomfort.

A nurse in a preoperative unit is caring for a client who is scheduled for surgery. The nurse is a witness on the client's consent form. The nurse provides a signature on the consent form for which of the following purposes?

Confirming the client appears competent to provide consent

A nurse manager is approached by two nurses who have a conflict that is disrupting the work on the unit. The nurse manager arranges a meeting with the two nurses and instructs them to work out the differences between themselves. Which of the following conflict resolution strategies is the nurse manager demonstrating?

Confrontation

A nurse providing dietary teaching to a client who has dysphasia following a stroke. Which of the following instruction should the nurse include in the teaching?

Flex your head with your chin tucked down to assist with swallowing

A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following tasks should the nurse instruct the UAP to complete first?

Obtain a capillary blood glucose for a client who is prescribed premeal insulin

A nurse manager is planning strategies to overcome resistance among unit nurses for a proactive policy change. Which of the following interventions should the nurse include?

Openly discuss the reason for the change.

A nurse is updating the plan of care for a client who has a new diagnosis of hypertension and a prescription for atenolol. Which of the following referrals should the nurse request from the provider as the priority referral?

Pharmacist

A client with gastrointestinal bleeding has a blood pressure of 84/48 mmHg and pulse of 138 beats per minute with respirations of 30 breaths per minute. Which of the following is the appropriate initial intervention for a nursing diagnosis of altered tissue perfusion related to decreased circulatory volume?

Place a large-bore intravenous catheter and administer a bolus of normal saline or lactated Ringer's.

Which of the following is correct concerning the nursing peer review process?

The performance appraisal should include other evaluation components in addition to the peer review

The charge nurse receives a call concerning a new client in the emergency room who is being admitted to the unit. The client has been experiencing generalized seizures of unknown etiology. To whom should the charge nurse assign this client?

The registered nurse

A nurse is planning an in-service with newly licensed nurses about safe delegation practices. The nurse should plan to refer the group to which of the following resources to guide delegation practices?

The state Nurse Practice Act

A charge nurse is delegating activities to a volunteer assigned to the pediatric unit. The nurse should identify that which of the following assignments is inappropriate to delegate to a volunteer?

Transporting a school-age child who is in traction to another department

A nurse is caring for a client who is confused and uncooperative. The assistive personnel (AP) who is working with the client asks if the client can be placed in restraints. The nurse should tell the AP that this action is a violation of the client's rights and is an example of which of the following torts?

False imprisonment

While administering medications to a group of clients on a medical-surgical unit, a client who is postoperative from an accidental above-the-knee amputation indicates to the nurse that he is ready to talk about his feelings. The nurse keeps her promise and returns to talk with the client as soon as she finishes administering medications. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A charge nurse observes that an assistive personnel (AP) is providing optimal care to clients. Which of the following actions should the nurse take first to recognize the AP's great work

Give positive feedback directly to the AP.

A nurse who is new to the unit experiences harassment, criticism, and passive-aggressive behavior when engaging with co-workers on a daily basis. These negative encounters are examples of which of the following?

Horizontal violence Rationale: Horizontal violence may occur as part of the nurse-nurse relationship, in which nurses who are of the same professional standing mistreat one another using actions or words. Examples of horizontal violence include intimidation, criticism, harassment, and interpersonal conflict. Horizontal violence that occurs in the workplace often causes pain and suffering for those who must endure it. Hazing refers to imposing humiliating tasks on a person as a form of initiation.

A nurse has assigned client care activities to an assistive personnel. Which of the following statements about the AP indicates a need for assistance with time management

I will start working with the client in room 1, then work my way to room 10.

A nurse works in a long-term care facility, where the residents wear street clothes and are not required to wear a hospital identification bracelet. What is an acceptable way for the nurses to identify the residents in order to administer medications?

Identify residents from their labelled photo on their medication administration record Rationale: Photos labelled with the resident's name can serve as a means of identification. In long-term care facilities where the clients remain for extended periods of time, visual recognition and a recent photo of the client are acceptable identifiers.

A nurse is caring for a client who returns his meal tray, each time with less than 10 percent of his food eaten. The nurse believes the client may have difficulty eating some of the foods on his tray. Since the nurse has identified a problem, which best describes the next step in the process of finding a solution?

Look for clues and further analyze the problem: identify any other signs that suggest the client is having difficulty eating.

A nurse is assessing a client in the emergency department who presented with epigastric pain and nausea. The client has a bluish discoloration around the umbilicus. Which of the following is the most appropriate initial nursing action? Show Explanation

Notify the healthcare provider Rationale: A bluish discoloration around the umbilicus is known as Cullen's sign. It reflects pancreatic necrosis or intraabdominal bleeding, typically in clients with pancreatitis. The healthcare provider should be notified.

A nurse is caring for a client who is 1 day postoperative following an abdominal hysterectomy. The assistive personnel (AP) reports to the nurse that the client's dressing is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

Obtain dressing supplies.

A charge nurse is delegating several client care tasks. Which of the following tasks should the nurse delegate to another Registered Nurse (RN)?

Obtaining a wound drainage specimen from a client who has a wound that is red and painful

A nurse manager is teaching a group of nurses about the Good Samaritan laws. Which of the following information should the nurse manager include?

Once aid is rendered, the nurse should not leave the scene until another qualified person can take over. Rationale: Guidelines for nurses who choose to render emergency care include: • If possible, limit actions to those that are generally included in first aid procedures. • Do not perform actions that you do not know how to do. • Offer assistance, but do not insist. • Have another person call or go for additional help. • Do not leave the scene until another qualified person takes over or the injured person leaves. • Do not accept any form of compensation for services rendered.

A nursing supervisor is planning an annual performance appraisal of a staff member on the unit. Which of the following actions should the nursing supervisor take?

Provide the staff member with a copy of the appraisal form in advance.

A nurse is observing an assistive personnel (AP) who is bathing a client in bed. The nurse should identify that which of the following actions by the AP indicates correct technique?

Pulling the curtain around the client's bed

A nurse manager receives a report that one of the staff nurses might be chemically impaired. Which of the following actions should the nurse manager take first?

Remove the nurse from client care. Rationale: Potential of Changes in Attendance of Chemically Impaired Staff Members • Absent from assigned shifts without adequate notice or explanation • Takes extended time away from care delivery during breaks and lunch • Excessive use of paid time off or sick days • Arrives to work early or stays late without apparent cause • Frequently disappears from the unit without explanation The nurse is responsible for reporting other members of the health care team whom they suspect might be working while impaired. This is an important tenet of the Nursing Code of Ethics, that the nurse's primary commitment is to the client and the nurse promotes the health and safety of self and others. It is important for the nurse to realize that reporting suspected impairment of another member of the health care team is not a form of betrayal but demonstrates commitment to the well-being of the team member and the safety of the clients. Additionally, there are legal ramifications for failure to report suspected impairment. If a state Board of Nursing investigation finds that other licensees, such as nurses, knew about the impairment and did nothing, the Board can also act against those individuals for failure to comply with the Nurse Practice Act.

A nurse notes an assistive personnel (AP) from the unit sharing a picture of a client's wound taken on their personal cell phone. Which of the following actions should the nurse take?

Report the occurrence to the charge nurse.

A home health nurse is interviewing the partner of a client who has heart failure. The client's partner states they are able to manage the day-to-day care of the client, but sometimes needs a chance to relax and have some time alone or with friends. The nurse should recommend a referral for which of the following?

Respite care

A nurse is providing change-of-shift report about a group of clients to the oncoming nurse. Which of the following information should the nurse include in the report?

"Mr. Rodriguez in room 200 needs another IV bag at 0700."

A nurse is assessing a group of clients for referrals. Which of the following clients should the nurse recommend for a referral to hospice services?

A client who has terminal cancer and requires assistance with pain management

Which of the following best describes an example of intrapersonal conflict?

A nurse wants to apply for a management position but feels as if she already spends too much time at work Rationale: Conflict occurs as a result of experienced or perceived variations in goals, values, ideas, attitudes, beliefs, feelings, or actions. Conflict may be interpersonal, intrapersonal, intergroup, or intragroup. Intrapersonal conflict occurs within one individual; interpersonal conflict occurs between two or more individuals; intragroup conflict occurs within one group; and intergroup conflict occurs between two or more groups. Conflict can be dysfunction or healthy.

Which of the following are the roles of a state board of nursing? (Select all that apply.)

A. Enforcing the State Practice Act for nurses C. Granting nursing licenses and overseeing licensing exams D. Disciplining nurses who have practiced in an unsafe manner Rationale: State boards of nursing are regulating agencies found within each state that play important roles in maintaining standards of nursing care and practice. State boards of nursing have several roles, including enforcing the State Practice Act found within each state, administering licensing exams and issuing licenses for nurses to practice, and disciplining nurses who have acted inappropriately. State boards may perform other duties, such as accrediting nursing schools within the state and developing practice standards.

Which of the following describes characteristics of a transformational leader? (Select all that apply.)

A. Engaging stakeholders in the leadership process C. Focusing on what others are trying to say E. Maintaining high levels of integrity and responsibility Rationale: A transformational leader is someone who embraces change and is adaptable to the working environment to facilitate change for the better. This type of leader promotes growth among those she leads. The transformational leader engages others in the leadership process and focuses on what they have to say, rather than assigning tasks from the top down. This type of leader also maintains high levels of integrity and is responsible for those she works with. Instead of commanding expectations, she consults and asks.

A nurse is reviewing ethical principles with a newly licensed nurse. Which of the following actions by a nurse is an example of adhering to the ethical principle of fidelity

A. Keeping an appointment with a client

A charge nurse on a medical-surgical unit has just been notified that the disaster protocol is being implemented following a natural disaster. Which of the following actions should the nurse take?

A. Make a list of clients who can be discharged. Rationale: Following the initiation of disaster protocol, the charge nurse should identify that clients who are stable can be discharged to allow clients who are harmed by the disaster to be admitted. The charge nurse should make a list of potential client dismissals and work collaboratively with providers to obtain discharge prescriptions. Clients Who Can Be Potentially Discharged Following a Disaster • Ambulatory clients who were admitted previously for observation • Ambulatory clients who admitted for undergoing diagnostic evaluation • Clients who are stable and can be cared for at home by family or support services • Clients who are stable and can be transferred to another facility • Clients who have remained stable for a minimum of 3 days

Which of the following are examples of a nurse case manager's activities? (Select all that apply.)

A. Witnessing informed consent B. Measuring and documenting client outcomes D. Teaching the client to be an advocate for himself Rationale: A case manager has many duties, including helping clients with complex health issues find appropriate resources, increase independence, and better manage their own health. Roles of the nurse case manager can include witnessing informed consent before a medical procedure, determining appropriate client outcomes, documentation, and instructing the client how best to advocate for himself. A nurse who is a case manager is a registered nurse who develops, implements, and evaluates individualized client care plans. Nurse case managers may function as social workers, advocate for client welfare, and act as a liaison between clients, their families, and other members of the healthcare team.

A nurse is caring for a client who fell and broke his hip while being assisted to the bathroom. The client states that he plans to sue the nurse. Which of the following individuals should define the standard of care that is used to establish whether the nurse was negligent in a court proceeding?

Another staff nurse Rationale: The definition of professional negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent individual who has a similar background and experience would do. Another staff nurse who practices in a similar setting to the nurse is the designated individual to provide testimony to define the standard of care.

An Orthodox Jewish client refuses a new prescription for omeprazole capsules for GERD. Which of the following actions is most appropriate for the nurse?

Ask the pharmacist if another form of the medication is available. Rationale: Capsule medications are generally coated in collagen from animals, a nonkosher substance that some Orthodox Jewish clients may refuse as unacceptable. In cases where another form of the medication is unavailable, it may be appropriate to consult with the client's rabbi to determine whether or not the dietary restrictions may be relaxed for the client.

A nurse and an assistive personnel (AP) are providing care to a group of clients. When planning task delegation, which of the following tasks should the nurse perform?

Assessing a client's sacrum for edema

A nurse is caring for a client with an asthma exacerbation who is complaining of shortness of breath and wheezing. Which of the following is the appropriate first nursing action?

Auscultate the lungs for wheezing and air movement.

Which of the following interventions should be implemented as part of safe medication administration practices? (Select all that apply)

B. Never administer medication that has been prepared by someone else E. Double check high-alert medications with another nurse before administering Rationale: Safe medication administration refers to implementation of evidence-based practices that reduce the risk of medication errors and client harm. The nurse should never administer a medication that has been prepared by someone else; never leave medications unattended at the bedside; keep all controlled substances in a locked area; only use verbal orders from a physician during emergencies; and double-check high-alert medications with another nurse before administration. Medications errors during medication administration frequently occur during prescribing, administration and monitoring. Errors can occur as a result of actions by healthcare providers, nursing staff, or clients. When administering a medication, safety measures include having the medication in a ready-to-use form; checking for allergies; giving the right medication to the right client, in the right dose, via the right route, at the right time; and appropriate documentation.

A health history and health assessment of a geographic community or a population should include:

C. Asset maps Rationale: Population and geographic health are assessed with data such as asset maps. Asset maps of a community include its strengths and weaknesses. Similar to individual client assessments, community assessments also collect data to generate a plan of care. Community health is a field of study which focuses on the maintenance, protection, and improvement of the health status of population groups and communities. Community health focuses more on a defined geographical community compared to public health. The health characteristics of the community may be examined using geographic information system (GIS) software and public health datasets. Asset maps will show the key services, benefits, and resources within the community that can be useful for the clients in that area.

A nurse working in the emergency department is caring for an adult client with appendicitis who only speaks Vietnamese. The physician wants to obtain consent for an appendectomy. The client's 15-year-old son is present and speaks English. The nurse should:

Call for a Vietnamese translator

A nurse is appointed as chairperson of the Policy and Procedures Committee at a 50 bed hospital. After reviewing the current procedures book, the nurse notices that there are no policies or procedures for use of equipment by personnel. Which of the following recommendations should the nurse make to correct the lack of policy and procedures concerning use of equipment?

Collect and publish the manufacturers' instructions for all pieces of equipment used by nursing staff

A nurse is caring for a client who is the neighbor of a nurse on another unit. The nurse from the other unit asks the nurse about the client's medical diagnosis. The nurse displays which of the following ethical principles by not divulging the information?

Confidentiality

A nurse is going through annual fire safety training. She reads a nearby fire extinguisher and sees that it is marked as class B. Which of the following materials would this fire extinguisher be designed to put out? (Select all that apply.) Show Explanation

Cooking liquids Oil Rationale: Class A fire extinguishers are used to extinguish fires from solid combustibles like wood, paper, and plastics. Class B extinguishers extinguish non-metals in a liquid state and flammable gases. Electrical equipment that is plugged in requires a class C extinguisher. A class D is only used in industries that use metals, including potassium, sodium, aluminum, and magnesium.

When using the mnemonic PASS to utilize a fire extinguisher, the A stands for:

D. Aim Rationale: Acronyms are used to help healthcare workers implement safety and emergency procedures. RACE is the acronym used when a fire is discovered. It stands for "RESCUE, ALARM, CONFINE, and EXTINGUISH/EVACUATE." PASS is the acronym used to recall the procedure for using a fire extinguisher. It stands for "PULL, AIM, SQUEEZE, and SWEEP."

A nurse is caring for a client with tachycardia who has a prescription for administration of metoprolol 5 mg IV push. The nurse is unsure whether he is permitted to push an IV medication. Where should the nurse look to find information related to his scope of practice in this situation?

D. Hospital policy and procedure manual

An RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

D. Inserting an indwelling urinary catheter for a client

A nurse is caring for a client who has been charged with a traffic violation that resulted in injuries to others. After a visit to the victims on the trauma floor, a local police officer visits your unit requesting information about the client. What is the appropriate response by the nurse?

D. Provide the officer with information regarding the privacy rule restriction according to HIPAA

A nurse manager is planning to teach the nurses on the unit about a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly?

Demonstrate using the device and observe the staff returning the demonstration.

A nurse manager is teaching a group of nurses about the civil judicial process. The nurse manager should include that witness depositions take place during which of the following steps?

Discovery step

An RN works for a temporary staffing agency for several night shifts each month in the Emergency Department. When entering the lounge during a break, the agency nurse is surprised by a senior staff nurse who is pouring from what appears to be a vodka bottle into a thermos cup. The staff nurse hurriedly closes the items in a locker but has exhibited loud and inappropriate behavior on several occasions in the past that now seem suspicious for intoxication at work. Which of the following is the most appropriate initial intervention by the agency nurse?

Discuss these concerns with the nursing supervisor.

What is the correct name for a document that identifies a legal proxy for making healthcare decisions in case the client is unable to make those decisions?

Durable power of attorney Rationale: A durable power of attorney is a type of advance directive that designates a person, known as a proxy, to make health care decisions on behalf of the client if the client becomes unable to do so during the course of his or her treatment. The durable healthcare power of attorney (POA) is a legal document that is signed and designated before the client undergoes treatment.

A charge nurse is teaching a newly licensed nurse about the quality improvement process in the acute care setting. The charge nurse should include which of the following in the teaching?

Employees at all levels of the organization should be involved in quality improvement

A nurse is documenting in the medical record information of a client in suspects opioid use disorder. Which of the following manifestation shit the nurse expect and document in the clients record?

Euphoria

The worker in the picture has the seat back at a 90-degree angle and is using lumbar support. The placement of the chair in this position most likely prevents which of the following conditions?

Excess pressure on the spine

Read the following graphic related to disaster management. Which of the following terms goes in the blank?

Response Rationale: The cycle of disaster management involves various steps that serve to plan for, respond to, and recover from a disaster. Before a disaster even occurs, professionals must plan for and take steps to prevent a disaster as much as possible. When a disaster happens, the next step is to respond to the disaster in order to promote recovery. The recovery process is then evaluated to determine what went well and what could be changed.

A nurse checks with assistive personnel on the unit throughout the shift to determine if assigned tasks are being completed in a timely manner. Which of the following rights of delegation is the nurse demonstrating?

Right supervision

A nurse is providing teaching about home tracheostomy care to the partner of a client who is to be discharged. When considering cost-effective care, which of the following instructions should the nurse give to the partner?

Rinse and dry suction catheters and reuse for up to 24 hr.

A nurse is completing an incident report for a client who has fallen. Which of the following actions should the nurse take?

Submit the incident report to the risk manager. Rationale: All unusual occurrences are recorded on an incident report form. Incidents that require the completion of an incident report can include a visitor fall or injury, medication error, not following a provider's prescription, an error in technique or procedure, or malfunctioning equipment. The incident report form should include the date, time, and place of the incident. The nurse should include a description of the occurrence with subjective and objective data, including the names of witnesses, medications by name and dosage, and equipment numbers. Nurses should never place a completed incident report form on the client's medical record or indicate in the client's medical record that one was completed. The nurse should document information about the fall or occurrence in the client's medical record. Incident reports are confidential tools used by the facility to improve client care.

An unconscious client arrives at the emergency department's trauma center by helicopter after a motorcycle accident in which the client was not wearing a helmet. The client arrives unaccompanied and has no identification on him, and his name and any other identifying information is not known. Due to the severity of his head injury and internal organ injuries, emergency surgery is required. Which of the following is the best next step with regard to obtaining informed consent for the surgeries?

Take the client to surgery without informed consent

An unlicensed assistive personnel (UAP) is assigned by the nurse manager to assist in moving a client with a stroke and right hemiparesis. The UAP tells the nurse manager that he doesn't remember how to use the mechanical lift. What is the appropriate response by the nurse manager?

Teach the person how to use the mechanical lift

A registered nurse delegates a routine task to the UAP. Which of the following best describes the legal consequences for the nurse if there is negligence by the UAP?

The RN may be liable if negligent in supervising the UAP

A nurse is witnessing a client's signature on a consent for a procedure. Which of the following will the nurse verify to ensure that the consent was obtained in an appropriate manner? (Select all that apply.)

There was adequate disclosure of information The client understood the information There was voluntary consent on the client's part The client has full awareness of the potential complications

A nurse is caring for a client who is scheduled for a total hip arthroplasty. Which of the following tasks is the nurse's responsibility?

Verify that the client understands the procedure they are having done.

A nurse receives a needle stick injury while administering IM pain medication to a client. Which of the following actions should the nurse take first

Wash the site of the injury with soap and water

A nurse is speaking with the partner of a client who has just expired. The transplant coordinator has spoken with the partner about organ donation. The client's partner reports uncertainty about donating organs. Which of the following responses should the nurse make?

What do you think your partner would have wanted?"

A nurse is using the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) technique to communicate with a provider about a client who is not responding to treatment. Which of the following information should the nurse include in the assessment portion of the communication?

What the nurse has identified as the problem

Which definition best describes moral distress in the nursing environment?

When a nurse knows the right thing to do but is constrained by certain institutional obligations that prevent the nurse from following through

A nurse and an assistive personnel (AP) are providing care to a group of clients. The nurse should delegate assisting which of the following clients with their meal to the AP?

A client who has a lumbosacral spinal tumor

A charge nurse is making team assignments for an Registered Nurse (RN) and a Licensed Practical Nurse (LPN). Which of the following clients should the charge nurse assign to the RN?

A client who is actively dying and requires IV pain medication

A nurse is caring for a group of clients and is delegating an assistive personnel (AP) to obtain vital signs. Which of the following clients should the nurse assign to the AP?

A client who is preoperative and scheduled for gastric bypass surgery

A charge nurse in the intensive care unit is assigning clients. Which of the following clients should be assigned to the most experienced nurse?

A. A client with a potassium level of 6.0 mEq/L who has peaked T waves

Which of the following are examples of a sentinel event? Select two.

A. A patient commits suicide in the hospital C. A surgeon performs wrong site surgery

A charge nurse is providing a staff inservice on care of the agitated or confused client. Which of the following alternatives to physical restraints will the nurse include in the information provided to the staff ? (Select all that apply.)

A. Involve family with monitoring the patient's activities B. Place a confused patient in a room closest to the nurses' station E. Use visual cues for distraction

A nurse is observing a newly licensed nurse insert an indwelling urinary catheter for an adult client. Which of the following actions by the newly licensed nurse requires intervention?

A. The nurse keeps the urine collection bag resting on the client's lap.

A nurse manager is planning an in-service about conflict management for the nurses on the unit. Which of the following situations should the nurse manager include as an example of interpersonal conflict?

An experienced nurse is uncivil to a newly licensed nurse.

A nurse is using the Situation, Background, Assessment, Recommendation (SBAR) format to contact a provider about a client who is postoperative following a total hysterectomy. The nurse should include information about the client's admitting diagnosis in which component of the SBAR report?

Background

A charge nurse is making assignments for the oncoming shift. Which of the following considerations should the charge nurse consider when making the assignments?

D. The physiologic status of the clients on the unit

A nurse who is employed at a community mental health center participates in a program to screen adolescents for substance use disorder. This type of intervention represents which of the following?

Secondary prevention

A nurse is admitting a client who is being evaluated for increased seizure activity at home. Which of the following tasks can the nurse delegate to the unlicensed assistive personnel (UAP) during admission of this client?

Setting up the client's room with supplies and equipment needed for seizure precautions

A nurse in a rehabilitation facility enters the dining room at mealtime and finds a client and his partner standing inside the room talking angrily about the client's care. The client's partner states loudly to the nurse, "My partner isn't getting any better and it's the fault of the staff here." Which of the following actions should the nurse take to decrease conflict?

Stand with her hands at her side when talking to the client and his partner.

A charge nurse is delegating tasks to a licensed practical nurse (LPN). Which of the following criteria is the priority for the charge nurse to consider when delegating?

State Nurse Practice Act

A nurse is planning to delegate tasks to an assistive personnel (AP). Which of the following factors should the nurse consider when using the five rights of delegation?

The AP's knowledge and skill to perform the task

A nurse has just received a report on a group of clients for the upcoming shift. Which of the following actions by the nurse demonstrates effective time management skills

Identify tasks there are times-specific

A nurse overhears two assistive personnel (AP) discuss a client's personal health information in the facility cafeteria. Which of the following is the priority action for the nurse to take?

Inform the APs that this is a breach in client confidentiality.

A charge nurse touches a staff nurse in a way that the staff nurse feels is inappropriate. Which of the following is the most appropriate initial action for the staff nurse to take?

Inform the charge nurse that the touch was inappropriate and must stop immediately.

A nurse in an emergency department is caring for a client who has a compression fracture of a spinal vertebra that requires surgery. The client has received morphine for pain, and the nurse is unable to contact the client's family. Which of the following actions should the nurse expect the neurosurgeon to take?

Invoking implied consent

A nurse manager is planning to announce a major change on the unit. Which of the following communication techniques should the nurse manager use to enhance the importance of the announcement?

Present the announcement to unit staff in a conference room.

A nurse is participating in a disaster simulation in which a toxic substance has been released into a crowded stadium. Multiple clients are transported to the facility. Which of the following actions should the nurse take first?

Prevent cross-contamination of clients

Which law protects the client's right to confidentiality and information security?

The Health Insurance Portability and Accountability Act

A nurse manager is discussing when to complete an incident report with a newly licensed nurse. For which of the following situations should the nurse complete an incident report?

The client discovers his dentures are missing

A nurse has shared his computer user name and password with a student nurse who is assisting with client care. Of the possible consequences associated with sharing this information, which of the following has the most significance?

The nurse can be prosecuted as a criminal

A nurse is obtaining informed consent from a client who is scheduled for a surgical procedure. Which of the following actions should the nurse take? (Select all that apply.)

Validate the signature is authentic. Verify the client's understanding of the surgical procedure. Confirm that the consent is voluntary.

A nurse is caring for an elderly client who has been diagnosed with lung cancer and is declining treatment. Which of the following ethical principles establishes the client's right to make decisions regarding his/her healthcare?

Autonomy

An RN and a licensed practical nurse (LPN) are receiving change-of-shift report on an assigned group of clients. Which of the following statements by the nurse giving report should indicate to the RN that she should assume total care for a client rather than assigning tasks to the LPN?

B. "The client's blood pressure and pulse have been fluctuating throughout the day."

A nurse is caring for a client who is newly diagnosed with metastatic lung cancer and declines treatment. Which of the following responses would indicate paternalism?

B. You should undergo the treatment recommended by your healthcare provider.

A nurse is caring for a client who is scheduled for surgery. The nurse should identify that which of the following actions is the responsibility of the nurse?

D. Determine the client's level of understanding about the procedure

A nurse and an unlicensed assistive personnel (UAP) are working together to care for a group of clients on the pediatric unit. Which of the following actions should the nurse request the UAP perform first?

D. Ensure the elbow restraint is in place for an infant who is postoperative following surgical correction of a cleft palate.

A nurse is conducting an education session about maintaining confidentiality of the electronic medical record (EMR) with a group of newly hired nurses. Which of the following statements by a newly hired nurse demonstrates an understanding of the information?

"I should log off the EMR on the client's in-room computer if I need to leave the room to collect supplies."

A nurse manager is presenting an in-service to staff nurses about methods to reduce the costs of client care delivery. Which of the following statements indicates an understanding of the teaching?

"I should use the minimum amount of dressings when providing wound care

A nurse is caring for a client who has Crohn's disease and is scheduled for a colon resection. The client states, "I have changed my mind and I don't want to have the surgery." Which of the following responses should the nurse make?

"I will notify the provider about your decision.

A nurse is teaching a client about choosing a health care surrogate. Which of the following statements by the client indicates an understanding of the teaching?

"If I become incapacitated, end-of-life choices will be made by my health care surrogate."

A client who has liver cancer informs the nurse that the provider has recommended that she consider receiving a liver transplant. The client tells the nurse she does not want to pursue this option because she "has already been through enough suffering." Which of the following responses should the nurse make?

"It is your right to make decisions regarding your care."

A newly licensed nurse asks the nurse manager whether they need to purchase their own professional liability insurance. Which of the following statements should the nurse manager make?

"Professional liability coverage is not mandatory, but you should consider purchasing your own coverage."

A nurse is teaching a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"The nurse should consider the AP's level of experience when making delegation decisions."

A nurse is completing a medication reconciliation with a newly licensed nurse on a client admitted to the unit from the emergency department. Which of the following statements by the newly licensed nurse indicates an understanding of the process?

"The purpose of medication reconciliation is to compare the medications a client is taking with newly prescribed medication."

A nurse is teaching a group of assistive personnel (AP) about performing hand hygiene. Which of the following statements should the nurse include in the teaching?

"You should avoid wearing artificial nails."

A nurse is assessing a client who experienced a traumatic brain injury. Which of the following findings is the nurse's priority?

3 cm (1 in) clear drainage from client's ear on gauze dressing

A nurse is caring for a client who has a terminal illness and is using a ventilator. The client is alert and oriented and tells the nurse he wants to discontinue the use of the ventilator. The nurse should identify that continued treatment against the client's wishes is a violation of which of the following ethical principles?

Autonomy

A charge nurse assigns a client's dressing change to a licensed practical nurse (LPN). Several hours later, the client reports that the dressing has not been changed. Which of the following actions should the charge nurse take?

Ask the LPN to discuss why the dressing change has not been completed.

An unlicensed assistive personnel (UAP) complains to a nurse that a client has been rude, demanding, and verbally abusive and refuses to care for the client due to this unpleasant behavior. Which of the following is the best initial response by the nurse?

Ask the UAP for more information and ask the UAP to discuss possible solutions to the problem.

Which skill do nurses need to adequately advocate for their clients, particularly when conflicts arise?

Assertiveness

A charge nurse is delegating tasks to nursing personnel on a ten-bed dementia care unit. Which of the following assignments is an example of overdelegation?

Assigning one AP to feed each client on the unit

A nurse is planning care for a client who has anorexia nervosa and has been admitted for cardiac arrhythmias. Which of the following client goals should the nurse identify as the priority?

Attain a weight that is greater than the 75th percent for ideal body weight.

A nurse on a quality assurance team is reviewing unit incident reports that were filed within the last six months. Which of the following incidents meets the criteria for a sentinel event?

C. A client who was having an anaphylactic reaction was administered epinephrine 0.75 mg intramuscularly. The client experienced a cardiac event and died.

Which of the following points relating to personal hygiene and the activities of daily living should you emphasize during an educational session for a group of newly employed nursing assistants?

C. Culture and cultural practices greatly affect the client's personal hygiene and activities of daily living

Which of the following is most likely utilized by an RN case manager? (Select all that apply)

C. Software for client data entry that integrates with predesigned templates to track care D. Integration of changes in regulations that affect reporting requirements by payer agencies or eligibility for healthcare benefits

A nurse is caring for a client who is actively dying. Which of the following actions by the nurse demonstrates the ethical principle of nonmaleficence?

C. Withholding a dose of pain medication when the client has respiratory depression

A nurse is caring for a client who becomes unresponsive and develops asystole. The family has previously requested that the client not be resuscitated. However, there is not a do-not-resuscitate (DNR) order from the provider in the client's chart. Which of the following actions should the nurse take?

Call the emergency response team.

A nurse is preparing to administer a bisacodyl enema to a client who has constipation. The client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following actions should the nurse take first?

Check the client's medication administration record for the provider's prescription.

A nurse is preparing to delegate the task of obtaining clients' vital signs to an assistive personnel (AP). Which of the following actions should the nurse plan to take?

Communicate the time frame for when the AP should report the results.

A nurse is participating on a quality improvement (QI) committee that is tasked with developing a program to reduce medication administration errors following a sentinel event at the facility. Which of the following actions should the committee take first?

Conduct a root cause analysis (RCA) on the error that occurred.

A nurse manager is working to maintain fiscal and ethical accountability for the staffing. Which of the following actions should the nurse take?

Create a sense of trust to resolve staffing issues.

A nurse is leading a group discussion about the risk factors of family and community violence. This nurse should include that which of the following clients has a risk factor for experiencing violence?

D. A 25-year-old female who is pregnant with her first child

A nurse is presenting an in-service on legal issues affecting nurses. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?

D. Battery

Read the following order from a physician. After reading the order, note which of the following nursing actions is most appropriate?

D. Contact the physician to clarify the order In this situation, the nurse must contact the physician to clarify the order. Ceftriaxone (Rocephin) is only administered in the IV or IM routes, never by mouth.

A nurse is caring for a client who has pneumonia. Which of the following tools should the nurse use to assist with providing cost-effective care?

D. Critical pathway

A nurse in a provider's office is reviewing the laboratory findings for a client who is receiving chemotherapy. The client has a platelet count of 60,000/mm3. Which of the following actions should the nurse take first?

Discuss these findings with the provider.

An unlicensed assistive personnel (UAP) reports to the nurse that a client was found on the floor. Which of the following should the nurse do after ensuring the client's safety?

Document the event in the client's medical record and have the UAP file an incident report

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should recognize that discontinuing this medication demonstrates which of the following ethical principles?

Nonmaleficence

A charge nurse is delegating tasks to a licensed practical nurse (LPN). Which of the following tasks should the charge nurse delegate to the LPN? (Select all that apply.)

Obtain vital signs from a client who is 6 hr postoperative. Administer a tap-water enema to a client who is preoperative. Catheterize a client who has not voided in 6 hr.

Two nurses are assisting a client with one-sided weakness to move up in bed. Which of the following describes the correct procedure with respect to optimal body mechanics?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client up

A nurse is planning care for a group of clients and assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

Reinforce teaching to a client about taking enoxaparin at home following a hip arthroplasty.

A nurse is preparing to delegate tasks to an LPN and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

Removing and cleaning the cannula of a client who has a stable, exisiting tracheostomy

A nurse notes that an unlicensed assistive personnel (UAP) has arrived late for work and appears disheveled, with bloodshot eyes and slurred speech. This UAP has a history of tardiness and forgetfulness. What is the appropriate action by the nurse?

Report the UAP to the nursing supervisor for suspected chemical impairment.