Leadership Final

A charge nurse is planning to delegate client care to a nurse. Which of the following actions should the nurse plan to take first? Determine client care a. assign a task to the nurse b. determine client care requirements c. clarify instruction with the nurse d. evaluate client outcomes

b. Determine client care requirements. The first action the charge nurse should take when using the nursing process is to assess the client to determine the care requirements in order to provide safe and effective care.

A nurse is documenting assessment findings on a client in the computer when an assistive personnel (AP) asks to use the computer to enter shift vital signs. Which of the following actions should the nurse take? a. Allow the AP to use the computer without logging out. b. Log out so the AP can use the computer. c. request that the AP write down the vital signs so the nurse can enter them. d. Have the AP ask another nurse to enter the vital signs.

b. Log out so the AP can use the computer. The nurse should log out of the computer after she has completed entering her assessment findings and allow the AP to enter vital signs on his assigned clients. This ensures that all client health information is secure and confidential.

A nurse is managing the care for a client who has recent unexplained weight loss and a low serum albumin level. Which of the following members of the interprofessional care team should the nurse consult? a. Occupational therapist b. Case manager c. Registered dietitian d.Social worker

c. Registered dietitian The nurse should consult a registered dietitian who will design a therapeutic diet, which will provide the client with needed nutrition to correct weight and protein loss.

A nurse in a mental health unit is admitting a client who has generalized anxiety disorder. Which of the following tasks should the nurse plan to include in the orientation phase of the relationship between the client and the nurse? a. Review the client's medical history. b. Explore the client's feelings associated with his condition. c. Develop a contract with the client about how private information will be handled. d. Explain strategies to the client for how he can handle problems independently.

c. Develop a contract with the client about how private information will be handled. The nurse should develop a contract with the client about how confidential information will be handled in the orientation phase of the nurse-client relationship. This phase sets the tone for the overall interaction and defines the primary purpose of the relationship. The major task of the nurse during this phase is to help the client clarify the current problem.

A charge nurse is reviewing the facility's confidentiality policies and procedures when assessing a client's personal health information with a newly licensed nurse. Which of the following actions by the new nurse requires interventions by the charge nurse? a. Pages a provider to a client's assigned room. b. Shows a client his electronic health record. c. Leaves an active computer screen unattended. d. Reviews a client's medication administration record with the pharmacist.

c. Leaves an active computer screen unattended. The newly licensed nurse should never leave an active computer screen unattended. This breaches client confidentiality according to facility policy and procedure. The nurse should always close all documents and log out when finished using the computer. This requires intervention by the charge nurse.

A nurse is planning care for a group of clients. Which of the following task should the nurse identify as requiring the use of informatics? a. Obtaining a 24-hr urine test b. Auscultating a client's bowel sounds c. Obtaining a client's oxygen saturation d. Performing a dressing change on a wound

c. Obtaining a client's oxygen saturation The nurse should identify that obtaining a client's oxygen saturation requires the use of a pulse oximeter, which is a form of informatics. A sensor probe is applied to the client's fingertip and, after 10 to 30 seconds, the computer detects the amount of percent oxygen in the client's blood. This allows the nurse to assess if the client is receiving enough oxygen or if the client needs supplemental oxygen.

A nurse is planning care for four clients. Which of the following tasks should the nurse delegate to a licensed practical nurse (LPN)? a. Assess a client's postoperative abdominal incision. b. Provide discharge teaching for a client who had a laparoscopic cholecystectomy. c. Perform a wet-to-dry dressing change for a client who has a pressure ulcer. d. Initiate a blood transfusion for a client who has a low hemoglobin

c. Perform a wet-to-dry dressing change for a client who has a pressure ulcer. Providing physical care to clients, such as dressing changes, is within the scope of practice for an LPN; therefore, the RN should delegate this task to the LPN.

A nurse is caring for a client who has a new diagnosis of Lyme disease. The client states, "I've decided on a therapy plane, but I wish I knew how this happened to me! I always take good care of myself" Which of the following responses should the nurse make? a. "You say you've made a decision about treatment, although you seem to be focusing on how it could've been prevented." b."I'm truly sorry about your recent diagnosis. It must be awful to be faced with this kind of news." c. "You shouldn't even think about why it happened. Focus your energy on therapy and feeling better soon." d. "I have taken care of many people with this disease, and they are always confused as to how they contracted it."

a. "You say you've made a decision about treatment, although you seem to be focusing on how it could've been prevented." In this response, the nurse is using the therapeutic communication technique of confrontation. When the nurse uses confrontation in a therapeutic way, it helps the client to realize inconsistencies in their behavior, recognize growth, and make important decisions.

A nurse is admitting a client who has an infected leg wound. The client states that he was treated 1 month earlier for the same condition. Which of the following actions should the nurse take? a. Review the client's data for treatment in the computer. b. Request that the client provide discharge paperwork from his previous facility visit. c. Contact the client's provider. d. Ask the client for a list of current medications.

a. Review the client's data for treatment in the computer. The nurse should review the client's electronic heath record about the infection of the leg wound and treatment that was provided. This will assist the nurse in determining if the treatment regimen needs to be changed.

A nurse is planning care for a client who has residual effects from an ischemic stroke. Which of the following interprofessional consults should the nurse require first? a. Speech-language pathologist b. Occupational therapist c. Physical therapist d. Social worker

a. Speech-language pathologist The greatest risk to this client is injury from aspiration; therefore, the nurse should first request a consult for a speech-language pathologist.

A nurse in the ED is completing a health history for a client who has DM. Which of the following questions should the nurse ask the client to assess his understanding of the primary health problem? a. "do you believe you are at risk of any health issues because of your lifestyle choices?" b. "How has your illness altered your typical daily activities?" c. "Is it easier for you to learn about blood glucose testing by observation or return demonstration?" d. "Have you explored alternative options from another clinics"

b. "How has your illness altered your typical daily activities?" This question by the nurse determines areas where the client may be deficient in knowledge or misinformed. Once it is determined how the illness affects the client's usual activities, the nurse can develop instructions for teaching the client how to self-manage the illness and provide information about available community resources.

A charge nurse is delegating client care for the oncoming shift. Which of the following tasks should the nurse delegate to assistive personnel (AP)? a. obtaining a wound culture from a client who has a stage II pressure ulcer b. collecting vital signs for a client who is on contact precautions c. teaching a client who is preoperative about how to perform leg exercise d. assisting a client to choose a meal containing low-sodium foods

b. Collecting vital signs for a client who is on contact precautions. An AP can take vital signs on a stable client who is on contact precautions.

A nurse is preparing to administer medication to a client using the medication bar scanning method. Which of the following actions should the nurse take first? a. Recheck the medication label with the medication administration record (MAR) in the computer. b. Scan the client's identification bracelet. c. Administer the medication to the client. d. Scan the barcode of the medication.

b. Scan the client's identification bracelet. The greatest risk to this client is injury from receiving the wrong medication; therefore, the nurse should scan the client's identification bracelet to confirm the client's identity and prevent a medication error.

A charge nurse is assigning client care for the oncoming shift. Which of the following tasks should the nurse assign to an RN? a. changing an appliance for a client who has an established ostomy b. providing postmortem care for a client c. calling a client to evaluate his condition 24 hr following discharge d. administering an oral medication to a client who has type 2 DM

c. Calling a client to evaluate his condition 24 hr following discharge. An RN is required to evaluate and assess a client.

A nurse in a rehabilitation facility is performing the role of a case manager for a group of clients. Which of the following actions should the nurse take? a. Offer the clients alternative therapies that differ from traditional Western medicine. b. Manage the day-to-day operation of a specific health care unit. c. Ensure clients receive optimal care in a cost-effective manner. d. Provide continuing education of nursing staff.

c. Ensure clients receive optimal care in a cost-effective manner. The responsibility of the case manager is to ensure clients receive optimal care in a cost-effective manner. A nurse often fulfills the role of case manager.

A charge nurse is teaching a class about the principles of delegation to a group of staff nurses. Which of the following information should the nurse include in the teaching? a. "an assistive personnel can delegate to another AP" b. "An RN should delegate a task that she does not have the skill to perform" c. "A delegator can delegate simple tasks to a client's family member" d. A delegator should delegate tasks that have predictable outcomes"

d. "A delegator should delegate tasks that have predictable outcomes." The delegator should delegate tasks that have predicable outcomes to ensure client safety. The delegator should verify that the delegate understands the expected outcomes of the task and what actions to take, such as notifying the nurse of unexpected outcomes.

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse attend to first? a. A client who is scheduled for discharge and requires teaching for wound care b. A client who is postoperative and requests pain medication before ambulation c. A client who is to receive an antibiotic in 1 hr and has a prescription for a peak and trough level d. A client who has received nitroglycerin sublingual for chest pain and requires a 12-lead EKG

d. A client who has received nitroglycerin sublingual for chest pain and requires a 12-lead EKG The first action the nurse should take when using the airway, breathing, circulation approach to client care is to obtain a 12-lead EKG for the client who is experiencing chest pain.

A charge nurse is assigning client care for the oncoming nursing shift. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)? a. initiating a blood transfusion for a client who has anemia b. creating a plan of care for a client who had a stroke c. evaluating dietary teaching for a client who has celiac disease d. administering a tube feeding for a client who has an established gastrotomy tube

d. Administering a tube feeding for a client who has an established gastrostomy tube. An LPN can administer the tube feeding for a client who has an established gastrostomy tube. An RN should initiate tube feeding for a client who has a new gastrostomy tube to verify tube placement and patency.

A nurse is creating a place of care for an older client who has a hearing impairment. Which of the following communication strategies should the nurse plan to use to enhance verbal dialogue with the client? a. gain the client's attention by initiating a conversation b. cup both hands around the mouth to project sound while facing the client c. increase the velocity and tone of voice when speaking to the client d. pause between sentences to verify the client's understanding

d. Pause between sentences to verify the client's understanding. The nurse should pause between sentences or phrases to verify that the client understands what is being verbalized. This strategy ensures proper communication skills with older adult clients, which helps to enhance verbal dialogue and minimizes confusion.

A nurse on a quality management team is developing written educational materials for clients who have varying degrees of health literacy. Which of the following strategies should the nurse include to aid the clients in effective learning? a. Write client instructional materials at an 8th grade reading level. b. Use passive voice in the third person when developing materials explaining medications to the client. c. Place priority instructions for the client in all capital letters at the end of the teaching materials. d. Provide instructional materials to the client that focus on desired behavior rather than medical facts.

d. Provide instructional materials to the client that focus on desired behavior rather than medical facts. The nurse should provide instructional materials to the client that focus on desired behavior rather than medical facts. The nurse should include the client in the teaching and provide information that will potentially change the client's behavior, rather than focusing on the behaviors that were caused by the client's lack of knowledge. This strategy will enhance the client's interest and desire to improve behaviors, which will decrease the risk of illness.