Leadership/ Management/ Delegation/ Prioritizing

166. The following four clients arrive at a nursing unit within 5 minutes of each other. Which client could the registered nurse (RN) safely assign to a licensed practical nurse/ licensed vocational nurse (LPN/ LVN) for admission procedures? 1. The client who fell in the hallway at a local nursing home and is admitted for orthopedic evaluation 2. The client who is transferred from the intensive care unit after observation for a head injury for 24 hours and is asleep 3. The client who is transferred from the emergency department after being treated for an acute asthma attack and is wearing an oxygen mask 4. The client who needs admission to the unit after being released from the postanesthesia care unit (PACU) following appendectomy and whose condition is stable

166. Answer: 4 Rationale: Option 4 is correct because the client will have been assessed by an RN immediately before discharge from the PACU. It would be the RN's assessment that would have indicated that the client was stable and eligible for discharge from the PACU. Option 1 is incorrect because the client who is admitted directly to a hospital unit has not been assessed by an RN within the inpatient setting. Option 2 is incorrect because a head-injured client must be assessed by an RN after transfer from the ICU. A client with an acute asthma attack has a priority airway problem. • Test-Taking Strategy: Focus on the subject, assignment to an LPN/ LVN. Noting the word "stable" will direct you to this option. • Review: delegation and assignments.

142. The night nurse received report from the evening nurse on assigned clients. Which client should the nurse determine as highest priority? 1. The client who is postoperative following an appendectomy, has complained of incisional pain of 5/ 10, received pain medication 1 hour ago, and is sleeping soundly. 2. The client who has diabetes mellitus, had a fasting blood glucose of 56 mg/ dL at 6: 00 am, and denies signs or symptoms of hypoglycemia; the last 15-minute blood glucose check after intervention was 65 mg/ dL. 3. The client who has heart failure, complained of shortness of breath during the night, and had fine crackles noted on auscultation in the lung bases; intravenous furosemide (Lasix) was prescribed, and vital signs are currently stable. 4. The client who was admitted during the night following an asthma attack and whose vital signs are: temperature 98.6 ° F; blood pressure (BP) 125/ 84 mm Hg; respirations 18 breaths per minute; heart rate 77 beats per minute; and pulse oximetry 98% with 2L of oxygen.

142. Answer: 2 Rationale: When determining which client to care for first, the nurse must consider the stability of each client based on the previous nurse's report. The client with diabetes mellitus whose blood glucose was low and continued to be low after intervention is the priority and requires follow-up and notification of the health care provider. The client who underwent appendectomy is sleeping soundly after receiving pain medication, and is a low priority. The client with heart failure who was exhibiting shortness of breath and whose vital signs are now stable is of intermediate priority. The client who was admitted following an asthma attack and whose vital signs are now stable is also an intermediate priority. • Test-Taking Strategy: Note the strategic words "highest priority." Noting that the clients described in the incorrect options are currently stable will assist you in answering correctly. • Review: guidelines for prioritizing.

171. The medical-surgical nurse is told to float to the intensive care unit (ICU) for the day because of short-staffing in the ICU. This nurse who has never worked in the ICU should take which action? 1. Go to employee health services for permission to go home 2. Call the ICU to let them know that an experienced staff nurse is not available 3. Inform the nursing supervisor of the lack of experience for working in the ICU 4. Ask another staff member who has floated to the ICU in previous short-staffing situations to report to the ICU

171. Answer: 3 Rationale: Nurses are sometimes required to "float" from the area in which they normally practice to other nursing units. The nurse should inform the nursing supervisor of the need to float, request an orientation to the unit, and identify the tasks that can be safely performed. Options 1 and 2 identify issues of possible client abandonment. Asking another staff member to report to the ICU is inappropriate. • Test-Taking Strategy: Focus on the subject, a lack of ICU nursing experience. Note the relationship of the data in the question and the correct option. • Review: staffing considerations and floating.

189. The charge nurse on a medical-surgical unit is using the concepts of leadership and management to ensure functionality of the unit. The nurse understands that, as a leader or manager (as opposed to a follower), it is necessary to have which primary ability? 1. Influence others 2. Follow guidelines 3. Use the chain of command 4. Provide feedback to supervisors

189. Answer: 1 Rationale: Leadership and management specifically involve influencing others to achieve goals and the accomplishment of tasks or goals by oneself or by directing others. The leader or manager must also follow guidelines, use the chain of command, and provide feedback to supervisors, but he or she primarily must be able to influence others. • Test-Taking Strategy: Note the subject, necessary attributes for a leader or manager, and note the strategic word, "primary." Eliminate options 2, 3, and 4 because they are comparable or alike in that they all note actions that imply following directions. Note that in order to be able to lead a group, a person must be able to influence others. • Review: leadership and management.

208. In the process of delegation, the nurse understands that the primary person who maintains accountability for the accuracy, safety, and completion of the task delegated remains with whom? 1. The delegator of the task 2. The delegatee of the task 3. Those who assisted with task completion 4. The person who documented task completion

208. Answer: 1 Rationale: The person who maintains accountability for the accuracy, safety, and completion of delegated tasks is the delegator. Although all personnel are responsible for their own actions, the primary person is the person who delegates the activity. • Test-Taking Strategy: Note the strategic word "primary." Eliminate options 2, 3, and 4 because they are comparable or alike in that they imply that those who take part in task completion and documentation are primarily accountable. • Review: delegation.

216. The nurse is taking a course on ethics as part of continuing education requirements in the state in which the nurse is employed. The nurse understands that respect for an individual's right to self-determination is identified by which term? 1. Justice 2. Fidelity 3. Veracity 4. Autonomy

216. Answer: 4 Rationale: Autonomy is the respect for an individual's right to self-determination. Justice is the equitable distribution of potential benefits and tasks determining the order in which clients should be cared for. Fidelity is the duty to do what one has promised. Veracity is the obligation to tell the truth. • Test-Taking Strategy: Note the subject, ethical principles. Note the relationship between the words "right to self-determination" and the correct option. • Review: autonomy and other ethical principles.

218. The nurse understands that an ethical dilemma exists in which scenario? 1. No correct decision exists 2. A satisfactory alternative is present 3. The right answer is always obvious 4. One ethical principle takes precedence over others

218. Answer: 1 Rationale: An ethical dilemma occurs when there is a conflict between two or more ethical principles. No correct decision exists, and the nurse must make a choice between two alternatives that are equally unsatisfactory. Options 2, 3, and 4 are incorrect. • Test-Taking Strategy: Focus on the subject, an ethical dilemma. Eliminate option 3 because of the closed-ended word "always." Recalling the definition of an ethical dilemma will assist in directing you to the correct option. • Review: ethical dilemma( s).

219. The nurse understands that which is the first step in the process of ethical reasoning in the management of an ethical dilemma? 1. Verbalize the problem 2. Negotiate the outcome 3. Consider possible courses of action 4. Examine one's own beliefs and values

219. Answer: 4 Rationale: The first step in the process of ethical reasoning is examining one's own beliefs and values. Next, verbalize the problem, consider the possible courses of action, negotiate the outcome, and evaluate the action taken. • Test-Taking Strategy: Note the strategic word "first." Recall that before any other actions are taken, the nurse must examine his or her own beliefs and values. • Review: ethical reasoning and ethical dilemmas.

221. Malpractice is determined if the nurse owed the client a duty and did not carry out the duty. What other aspect is required for malpractice to have occurred? 1. The client was injured 2. The client felt neglected 3. The client's family was affected 4. The client's state was unchanged

221. Answer: 1 Rationale: Malpractice is determined if the nurse owed the client a duty and did not carry out the duty and the client was injured as a result of the nurse's negligence. Options 2, 3, and 4 are incorrect. • Test-Taking Strategy: Note the subject, nursing actions required to constitute malpractice. Recall that the client must have been injured in order for malpractice to have occurred. • Review: malpractice.

210. The registered nurse (RN) working in the long-term care facility is planning client assignments for the day. Which priority consideration should the nurse remain mindful of when preparing the assignments? 1. Client safety 2. Delegatable tasks 3. Individual variations in work ability 4. Matching tasks to the appropriate worker

210. Answer: 1 Rationale: The priority consideration when planning client assignments is client safety. The nurse should also consider delegatable tasks, individual variations in work ability, and matching tasks to the appropriate worker, but these are not the priority considerations at this time. • Test-Taking Strategy: Note the strategic word "priority." Eliminate options 3 and 4 because they are comparable or alike. Use Maslow's Hierarchy of Needs theory to assist in directing you to the correct option. • Review: assignments.

154. Which situation( s) are classified as natural disasters? Select all that apply. 1. Blizzards 2. Terrorist attacks 3. Volcanic eruptions 4. Structural collapse 5. Communicable diseases

154. Answer: 1, 3, 5 Rationale: Examples of natural disasters include the following: blizzards; volcanic eruptions; communicable diseases; cyclones; droughts; earthquakes; floods; forest fires; hailstorms; hurricanes; landslides; mudslides; tidal waves; and tornadoes. Terrorist attacks and structural collapse are classified as human-made disasters. • Test-Taking Strategy: Note the subject, natural disasters. Note that terrorist attacks and structural collapse do not occur as a result of nature, but rather as a result of the actions of humans. • Review: natural disasters and human-made disasters.

225. The nurse working on a medical-surgical unit has received the assignment and the report on the assigned clients. Which client should the nurse care for first? 1. The client with urosepsis who is on oral antibiotics and had a temperature of 99.2 ° F. 2. The client who is status post-brain attack (stroke) and continues to exhibit signs of unilateral weakness. 3. The client with a tracheostomy who did not require suctioning during the previous shift and whose oxygen saturation is 99%. 4. The client with chronic obstructive pulmonary disease (COPD) who required two respiratory treatments during the previous shift.

225. Answer: 4 Rationale: The nurse should first care for the client with COPD who required two respiratory treatments during the previous shift because this indicates that the client has been experiencing respiratory difficulty. The client with urosepsis on oral antibiotics whose temperature is 99.2 ° F does not suggest any current distress but requires continued monitoring. The client who is status post-brain attack (stroke) and exhibiting signs of unilateral weakness is not showing any signs of further distress. The client with a tracheostomy who did not require suctioning and whose oxygen saturation is 99% is also considered stable at this time. • Test-Taking Strategy: Note the strategic word "first." Recognize that the client with COPD who required respiratory treatments was experiencing respiratory distress. Use the ABCs—airway, breathing, and circulation—to assist in directing you to this option. • Review: guidelines for prioritizing.

135. The nurse is assisting in responding to a disaster. Which personal item( s) should the nurse ensure are taken to the scene? Select all that apply. 1. Warm clothing 2. Large jugs of water 3. Copy of nursing license 4. Record-keeping materials 5. Personal health care equipment

135. Answer: 1, 3, 4, 5 Rationale: When assisting in responding to a disaster, the nurse should bring warm clothing, a copy of the nursing license, record-keeping materials, personal health care equipment, and other nursing supplies. Disaster relief agencies will provide other life-sustaining materials that are necessary. Additionally, large jugs of water are difficult to carry. • Test-Taking Strategy: Note the subject, personal items that should be brought to the scene of a disaster. Recalling that large jugs of water are provided by disaster relief agencies will assist you in eliminating this option. • Review: disaster management.

132. A disaster that results in significant damage and presidential disaster declaration is classified by the Federal Emergency Management Agency (FEMA) as which level? 1. Level I 2. Level II 3. Level III 4. Level IV

132. Answer: 1 Rationale: According to FEMA, a level I disaster is a massive disaster that involves significant damage and results in a presidential disaster declaration, with major federal involvement and full engagement of federal, regional, and national resources. A level II disaster is a moderate disaster that is likely to result in a presidential declaration of an emergency, with moderate federal assistance. A level III disaster is a minor disaster that involves a minimal level of damage, but could result in a presidential declaration of an emergency. Level IV is not a part of this classification system. • Test-Taking Strategy: Focus on the subject, levels of disaster identified by FEMA. Note the relationship between the words "significant damage" and the correct option. • Review: disaster management.

133. The unlicensed assistive personnel (UAP) reports to the registered nurse (RN) that an assigned client is experiencing difficulty breathing. Which action should the RN take first? 1. Call respiratory therapy 2. Notify the client's family 3. Obtain a set of vital signs 4. Call the health care provider (HCP)

133. Answer: 3 Rationale: The nurse should obtain a set of vital signs of the client who is experiencing respiratory difficulty before contacting respiratory therapy or the HCP because this information will need to be reported to these members of the health care team. While it is appropriate to notify the family of the change in the client's condition (if indicated by the client in writing), it is not the priority at this time. • Test-Taking Strategy: Note the strategic word "first." Use the steps of the nursing process. The nurse needs to obtain a set of vital signs so that this data can be reported to respiratory therapy and/ or the HCP. • Review: prioritizing care.

134. The nurse uses the principle of beneficence in which situation? 1. The nurse is fair in providing resources to all clients 2. The nurse follows through with care offered to a client 3. The nurse respects the client's right to determine a course of action 4. The nurse tells the client that the flu shot may cause some discomfort but describes the benefits of the immunization

134. Answer: 4 Rationale: Beneficence is described as taking a positive action to help others. Commitment to beneficence helps to guide decisions when the benefits of treatment are challenged by its risks. Option 1 describes justice. Option 2 describes fidelity. Option 3 describes autonomy. • Test-Taking Strategy: Focus on the subject, beneficence. Recalling that this ethical term refers to the commitment to help others will direct you to the correct option. • Review: ethical principles.

131. Which nursing action( s) can result in disciplinary action by state boards of nursing? Select all that apply. 1. Release of client health information to a client's neighbor 2. Delegation of a dressing change to unlicensed assistive personnel (UAP) 3. Release of client health information to the client's durable power of attorney 4. Administration of a routine immunization that resulted in an allergic reaction 5. Administration of an injection to a client who stated refusal of the medication

131. Answer: 1, 2, 5 Rationale: Nursing actions that can result in disciplinary action include unprofessional conduct; conduct that could adversely affect the health and welfare of the public; breach of client confidentiality; failure to use nursing skills, knowledge, or judgment; verbal or physical abuse; assuming duties without sufficient preparation; knowingly delegating to a UAP nursing care that places the client at risk for injury; failure to maintain an accurate record of client care; falsifying a client's record; and leaving a nursing assignment without properly notifying the appropriate personnel. Option 1 constitutes breach of client confidentiality. Option 2 identifies improper delegation procedures outside of the UAP's scope. Option 5 constitutes battery and is an illegal act. Option 3 is acceptable. An allergic reaction is not a reason for disciplinary action. • Test-Taking Strategy: Focus on the subject, actions that can result in disciplinary action. Analyze each option to determine whether they violate any legal or ethical standards. • Review: ethical and legal issues.

199. The quality improvement nurse working in the long-term care setting is performing an evaluation and is using past medical records after the client's discharge for documentation of compliance with standards. What type of evaluation is being performed by the nurse? 1. Peer review 2. Concurrent review 3. Retrospective review 4. Multidisciplinary review

199. Answer: 3 Rationale: A retrospective review uses past medical records after the client's discharge for documentation of compliance with standards. A peer review is a process in which nurses employed in an organization evaluate the quality of nursing care delivered to the client. A concurrent review is an evaluation method used to inspect compliance of nurses with predetermined standards and criteria. A multidisciplinary review is not a specific type of evaluation method. • Test-Taking Strategy: Focus on the subject, quality improvement and types of reviews. Note the relationship between the words "past medical records" and "retrospective" in the correct option. • Review: quality improvement.

200. The nurse educator is conducting a teaching session on Lewin's basic concepts of the change process and is describing the phases of change. The educator describes one phase as the time when change is planned and implemented. Which stage is being described? 1. Staging 2. Refreezing 3. Unfreezing 4. Moving and changing

200. Answer: 4 Rationale: There are three phases of the change process according to Lewin, and these phases include unfreezing (the problem is identified, and individuals involved gather facts and evidence supporting a basis for change); moving and changing (change is planned and implemented); and refreezing (change becomes stabilized). Staging is not a part of this process. • Test-Taking Strategy: Note the subject, phases of the change process described by Lewin. Note the relationship between the words "the time when change is planned and implemented" and the correct option. • Review: the change process.

224. The nurse who is off-duty stops at the scene of an accident and provides first aid care to injured clients. One of the clients develops complications associated with the injuries obtained by the accident. The nurse is immune from a malpractice lawsuit unless the nurse took which action? 1. Followed state practice laws 2. Provided care in a reasonable manner 3. Provided care that was not intentionally negligent 4. Administered care outside of the scope of practice based on experience

224. Answer: 4 Rationale: Good Samaritan laws encourage health care professionals to assist in emergency situations and limit liability and offer legal immunity for persons helping in an emergency, provided they give reasonable care. Immunity from lawsuit only applies when all conditions of the state laws are met, such as receiving no compensation, giving care that is not intentionally negligent, and providing care within the scope of practice. Therefore, options 1, 2, and 3 are incorrect. • Test-Taking Strategy: Note the subject, Good Samaritan laws. Recall that if the nurse provides care outside the scope of practice, then the nurse is not immune from malpractice lawsuits. • Review: Good Samaritan laws.

227. When prioritizing the care for a group of clients, the nurse should remain mindful of which item as the highest priority? 1. Safety needs of clients 2. Spiritual needs of clients 3. Client perception of time 4. Physiological needs of clients

227. Answer: 4 Rationale: When prioritizing the care for a group of clients, the nurse should remain mindful of the physiological needs of clients as the highest priority. Safety and spiritual or psychosocial needs follow, respectively. Client perception of time is important and should be addressed in the care of clients, but physiological needs come first. • Test-Taking Strategy: Note the strategic word "highest priority." Use Maslow's Hierarchy of Needs theory in order to answer this question correctly. • Review: guidelines for prioritizing.

136. A client admitted to the hospital has a diagnosis of syncope. The client is taking enalapril (Vasotec), atenolol (Tenormin), and aspirin (ASA) daily but says that the medications were prescribed by different health care providers. The admitting health care provider wrote in the client's prescription sheet, "Administer medications as taken at home." Which is the most appropriate action for the nurse to take? 1. Administer the medications as prescribed by the health care provider. 2. Call the health care provider, describe the medications, and request prescription clarification. 3. Refuse to give any medications, and wait until the health care provider makes rounds to clarify the prescriptions. 4. Send the client's medication bottles to the pharmacy for identification, and then administer the medications as prescribed.

136. Answer: 2 Rationale: The nurse is responsible for administering the correct medication. When medication prescriptions are vague or confusing, the nurse must call the health care provider to clarify the prescriptions before administering the medication. Therefore, options 1, 3, and 4 are incorrect actions. • Test-Taking Strategy: Note the strategic words "most appropriate." Options 1 and 4 are comparable or alike in that they indicate administering the medication and are therefore eliminated first. Eliminate option 3 next because it is not appropriate to wait to clarify an unclear prescription. • Review: medication prescriptions guidelines.

137. The nurse has responded to the scene of a disaster and the first victim that the nurse encounters is one who has a large wound on the leg that is actively bleeding. The nurse should identify this victim as belonging to which classification? 1. Urgent 2. Delayed 3. Emergent 4. Non-urgent

137. Answer: 3 Rationale: Victims who have active bleeding are considered to have a life-threatening condition and should be classified as emergent, requiring care of the condition that is readily correctable. A victim who is classified as urgent must be treated within 1 to 2 hours. A victim who is classified as delayed (non-urgent) has no injury, has an injury that is not critical, or is ambulatory. • Test-Taking Strategy: Eliminate options 2 and 4 because they are comparable or alike. From the remaining options, recall that active bleeding is easily correctable but can be life-threatening if not treated immediately. • Review: triage.

138. A hospitalized client with a history of alcohol abuse tells a nurse, "I'm leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." What action should the nurse take when a client decides to leave against medical advice (AMA)? 1. Call the nursing supervisor 2. Call security to block all exit areas 3. Place the client in seclusion, and contact the health care provider for further instruction 4. Tell the client that he or she must contact the health care provider before leaving the hospital

138. Answer: 1 Rationale: A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when the client leaves AMA. The client should be asked to sign this document before leaving. Secluding the client and calling security to block exits constitutes false imprisonment. The nurse should request that the client wait to speak to the health care provider before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. • Test-Taking Strategy: Keeping the concept of false imprisonment in mind, eliminate options 2 and 3 because they are comparable or alike. Note the word "must" in option 4; the nurse is demanding the client stay until the health care provider is notified. • Review: legal and ethical principles.

139. Which client( s) may be assigned to a licensed practical nurse/ licensed vocational nurse (LPN/ LVN)? Select all that apply. 1. The client requiring oral medications 2. The client requiring admission assessment 3. The client requiring an intravenous injection 4. The client requiring a subcutaneous injection 5. The client requiring an intramuscular injection 6. The client requiring insertion of a Foley catheter

139. Answer: 1, 4, 5, 6 Rationale: An LPN/ LVN may administer all types of medications except intravenous injections and is trained to insert a Foley catheter. Assessment and administration of intravenous medications are responsibilities of the registered nurse (RN). • Test-Taking Strategy: Focus on the subject, delegating and assignment-making principles. Remember that an LPN/ LVN can perform many treatments and procedures and can administer all types of medications except intravenous injections. Also recall that assessment is the responsibility of the RN. • Review: delegation and assignments.

140. The nurse on the postsurgical unit receives a client that was transferred from the postanesthesia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client's discharge at which point during the hospitalization? 1. Is admitted to the surgical unit 2. Is transferred from the PACU to the postsurgical unit 3. Is able to perform activities of daily living independently 4. Has been assessed by the health care provider for the first time after surgery

140. Answer: 1 Rationale: Discharge planning begins when the client is admitted to the hospital or health care facility. Since the client is being transferred from one unit to another, discharge planning should have begun when the client was admitted to the surgical unit. It is the nurse's responsibility who is receiving the client to provide for continuity of care and update and carry out the discharge plans that have previously been delineated. Options 2, 3, and 4 are inaccurate times to begin discharge planning. • Test-Taking Strategy: Note the subject, the timeframe in which discharge planning should be initiated. Recalling that discharge planning begins as soon as the client is admitted to the health care facility will assist you in eliminating options 2, 3, and 4. • Review: discharge planning.

141. The nurse acts as a client advocate in which situation( s)? Select all that apply. 1. Pulling the curtain around the client's bed while changing a dressing. 2. Contacting the health care provider to request a meeting for the client. 3. Ensuring access to medical information by appropriate personnel only. 4. Providing the client with requested information regarding support groups. 5. Questioning the health care provider regarding a discrepancy in reported medication dosages between the home and hospital setting.

141. Answer: 2, 5 Rationale: An advocate is a person who speaks up for or acts on behalf of the client. An advocate represents the client's viewpoints to others. Requesting a meeting with the health care provider for the client and questioning the health care provider regarding the client's concern with a discrepancy in medication dosage are instances in which the nurse is acting as a client advocate. Pulling the curtain around the bed during a dressing change maintains privacy. Ensuring access to medical information by appropriate personnel only, maintains confidentiality. Providing the client with requested information regarding support groups upholds fidelity. • Test-Taking Strategy: Note the subject of the question, client advocacy. Recalling the definition of advocacy will assist in directing you to the correct options. • Review: ethical principles.

143. The nurse enters a client's room and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was voluntary. Which intervention should the nurse initiate first? 1. Telephone the client's family, and have them persuade the client to stay 2. Have the client read and sign all of the appropriate self-discharge papers 3. Explain to the client that he cannot leave because he asked for treatment 4. Notify the client's health care provider of the client's stated intent to leave the hospital

143. Answer: 4 Rationale: Generally, voluntary admission is sought by the client. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. Many states require that the client submit a written release notice to the facility staff, who reevaluate the client's condition for possible conversion to involuntary status, according to criteria established by law. Options 1 and 3 violate the client's rights. Although the client may need to sign appropriate discharge papers, the nurse should contact the health care provider first. • Test-Taking Strategy: Note the strategic word "first." Noting the type of hospital admission will assist you in eliminating option 3. Option 1 should be eliminated because of client rights and the subject of confidentiality. Option 2 does not relate to the subject of the question. • Review: voluntary and involuntary admission procedures.

144. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent? 1. Obtain a court order for the surgery 2. Sign the informed consent on behalf of the client 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from the family member, with the consent being witnessed by two health care providers

144. Answer: 4 Rationale: Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. Options 1, 2, and 3 are not appropriate. • Test-Taking Strategy: Note the strategic word "best." Use knowledge about the implications of informed consent, and select option 4 because it is legally acceptable to obtain a telephone permission from a family member if it is witnessed by two persons. • Review: informed consent.

145. Which client( s) should the emergency department triage nurse classify as urgent? Select all that apply. 1. A client with a swollen ankle after a fall 2. A client with an acute exacerbation of asthma 3. A client with an open fracture of the left femur 4. A client with abdominal pain and no other symptoms 5. A client with the "worst headache of [the client's] life"

145. Answer: 1, 4 Rationale: Emergent refers to a client that must be treated immediately otherwise life, limb, or vision is threatened. Urgent refers to a client requiring treatment but life, limb, or vision is not threatened if care cannot be provided within 1 to 2 hours. The clients in options 1 and 4 are classified as urgent requiring care within 1 to 2 hours. Nonurgent refers to a client requiring care and possible treatment, but time of care is not a factor. Options 2, 3, and 5 should be treated as emergent. The client in option 2 could experience respiratory compromise if oxygen levels decrease. The client in option 3 could experience permanent nerve injury as a result of the open fracture. The client in option 5 could possibly be experiencing rupture of a cerebral aneurysm. • Test-Taking Strategy: Note the subject, triage classification as urgent. Recall that the client classified as urgent may wait for treatment for a brief period of time because the client does not demonstrate an immediate threat to life at the moment. The options that do not indicate an immediate threat to life, limb, or vision are options 1 and 4. • Review: triage principles.

146. When a manager is interviewing a newly graduated nurse for an evening position on an orthopedic unit, the manager states that she makes client assignments for the evening and night staff so that the staff members can immediately focus on client care. The graduate meets with the evening staff and asks which question to validate the graduate's impression that the manager is autocratic? 1. "Does the manager foster dependency?" 2. "Does the manager promote planning by the group?" 3. "Does the manager ask for ideas from staff when decisions need to be made?" 4. "Does the manager show different leadership styles depending on the needs of the staff?"

146. Answer: 1 Rationale: A manager who makes assignments for all staff members creates a dependency on the manager for direction. Such a manager is considered autocratic. A manager who promotes group planning or asks for ideas from the staff is considered democratic or participative. A manager who shows different leadership styles based upon the needs of the staff is described as a situational leader. • Test-Taking Strategy: Note the strategic word "immediately," and note the relationship between the subject "autocratic" and the words "foster dependency" in the correct option. • Review: leadership styles.

147. The nurse is caring for an involuntarily committed client who has been premedicated for scheduled electroconvulsive therapy (ECT). When reviewing the chart, the nurse fails to find an informed consent for the procedure. Based on this information, the nurse should give which intervention priority? 1. Notify the client's health care provider 2. Have the client sign an informed consent for the scheduled procedure 3. Realize that an informed consent is not required when the admission is involuntary 4. Explain to the client that the health care provider will be in to obtain an informed consent

147. Answer: 1 Rationale: Clients who are involuntarily admitted do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client but since the client has been premedicated, he is not capable of giving consent. Option 1 has priority because it addresses the problem. Option 2 is incorrect because the health care provider is responsible for explaining the risks and then obtaining the consent. The nursing responsibility lies in assuring that the consent has been obtained. Option 4 is appropriate but not the priority intervention. • Test-Taking Strategy: Note the strategic word "priority," and note the type of hospital admission and the subject, informed consent. Thinking about client's rights will direct you to the correct option. • Review: voluntary and involuntary admission procedures and informed consent.

148. The nurse manager is confronted by an angry health care provider who states, "You run the most inefficient unit in the hospital. I asked for my charts to be pulled and set up in a rack for rounds, and it is never ready when I arrive!" What is the manager's most appropriate response/ action to the health care provider? 1. Smile and ask, "Having a bad day?" 2. Remain silent, and then make a neutral response 3. "Stop. I have no idea what you are talking about." 4. "The hardest working people in this hospital are on this unit, and we are not here to simply respond to your every wish."

148. Answer: 2 Rationale: During confrontation, it is best to allow a little time to let the confronter get feelings out. Option 1 is incorrect because it trivializes something that is clearly upsetting to the health care provider. Option 3 is incorrect because it will incite additional commentary and to admit that the manager does not know what transpires on a unit for which the manager is responsible could be interpreted as incompetence. Option 4 is incorrect because the manager has failed to keep the anger under control. • Test-Taking Strategy: Note the strategic words "most appropriate," and use therapeutic communication techniques. This will direct you to the correct option. • Review: conflict and therapeutic communication techniques.

149. The nursing supervisor is preparing an inservice presentation on disasters and the phases of disaster preparedness. The nurse plans to inform the group attending the presentation that the determination of resources available for care to infants, older adults, disabled individuals, and individuals with chronic health problems is part of which phase of disaster preparedness? 1. Recovery 2. Response 3. Mitigation 4. Preparedness

149. Answer: 3 Rationale: The phases of disaster preparedness include mitigation, preparedness, response, and recovery. Mitigation includes, among other things, determination of the resources available for care to infants, older adults, disabled individuals, and individuals with chronic health problems. Response encompasses putting disaster planning services into action and the actions taken to save lives and prevent further damage. Recovery involves the actions taken to return to a normal situation after a disaster occurs. Preparedness involves plans for rescuing, evacuation, and caring for disaster victims. • Test-Taking Strategy: Focus on the subject, the determination of resources and recognize the relationship between resource availability and the definition of mitigation. • Review: phases of disaster management.

150. Which scenario( s) represents malpractice on the part of the nurse? Select all that apply. 1. Failure to monitor a client's condition. 2. Failure to check equipment for proper functioning. 3. Failure to provide a complete report to the oncoming nursing staff. 4. Failure to regulate the temperature of a bath resulting in a burn on a client. 5. Failure to implement proper safety precautions resulting in a client falling and sustaining a fracture to the ankle.

150. Answer: 4, 5 Rationale: Malpractice is determined if the nurse owed a duty to the client and did not carry out the duty and the client was injured because the nurse failed to perform the duty. Negligence is conduct that falls below the standard of care and includes both acts of commission and acts of omission. Options 4 and 5 identify actions (a lack thereof) on the part of the nurse that result in injury. Options 1, 2, and 3 represent negligence wherein these actions fall below the standard of care but did not result in client injury. • Test-Taking Strategy: Note the subject, malpractice. Recalling the difference between malpractice and negligence will direct you to the correct options. • Review: ethical and legal principles.

151. The graduate nurse is told that the nurse manager's leadership style is one of letting the staff nurses make the decisions about the unit's operations. When the graduate nurse meets with the nursing staff, which question should the graduate nurse ask to confirm that the nurse manager's leadership style is laissez-faire? 1. "Does the manager facilitate decision making by the group?" 2. "Does the manager maintain control and make all decisions?" 3. "Does the manager assume a passive, nondirective approach?" 4. "Does the manager change her style according to needs of the group?"

151. Answer: 3 Rationale: A laissez-faire leader assumes a passive, nondirective approach. Option 1 describes a democratic leader—the type of leader who talks with the members to gain input and facilitate decision making by the group. Option 2 describes an autocratic leader—the type of leader who makes the decisions. Option 4 describes a situational leader—the type of leader who for some situations makes the decisions and for other situations asks the staff nurses to decide. • Test-Taking Strategy: Note the subject, "letting the staff nurses make the decisions." Note the relationship between these words and the words "passive, nondirective" in the correct option. • Review: leadership styles.

190. The nurse is preparing a client for discharge and is performing a variance analysis on a client. The nurse notes that the client is being discharged earlier than anticipated. The nurse understands that this client outcome is characteristic of which type of variance? 1. Positive 2. Negative 3. Unchanged 4. Unexpected

190. Answer: 1 Rationale: Variance analysis is a continuous process that the case manager or other caregivers conduct by comparing specific client outcomes with the expected outcomes described on the critical pathway. A positive variance occurs when a client achieves maximum benefit and is discharged earlier than anticipated on the critical pathway. Options 2, 3, and 4 are incorrect. • Test-Taking Strategy: Note the subject, variance analysis. Note the relationship between the words "discharged earlier than anticipated" and the correct answer. • Review: variance analysis.

152. The nurse manager announces to nursing staff that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? 1. "The client population that the health care system services present particular challenges. The changes made will enhance client safety and reduce errors." 2. "If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance—which could lead to termination of your employment." 3. "Every manager has the responsibility to see that this new policy and procedure is followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4. "You can trust me on this one. I was a member of the committee that wrote the policy and procedure, and it is very clear there are good reasons why the specific nursing actions need to be done this new way."

152. Answer: 3 Rationale: Legitimate power is based upon a person's position within an organization or society. The organizational leadership has mandated performance outcomes, and management carries the responsibility to see that the mandate is met. Option 1 demonstrates informational power. Option 2 reflects an example of coercive power. Option 4 reflects expert power. • Test-Taking Strategy: Note the strategic words "legitimate power." Think about the description of the types of power. The correct option best reflects legitimate power. • Review: types of power.

153. For which client situation would a consultation with a rapid response team (RRT) be most appropriate? 1. 45-year-old; 2 years post-kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4 ° F; heart rate 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/ 72 mm Hg; is restless 2. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8 ° F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/ 86 mm Hg; anxious about going home 3. 56-year-old; fourth hospital day after coronary artery bypass procedure; sore chest; pain with walking; temperature 97 ° F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 98/ 72 mm Hg; bored with hospitalization 4. 86-year-old; 48 hours postoperative repair of fractured hip (nail inserted); alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8 ° F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/ 62 mm Hg; talking with daughter

153. Answer: 1 Rationale: The role of an RRT is to respond to emergency calls usually from nurses and according to established protocols, to intervene rapidly for clients who are beginning to clinically decline. Option 1 describes a client who may be rejecting the transplanted kidney. The constellation of symptoms described indicates possible rejection. Options 2, 3, and 4 indicate expected characteristics of the clients described and provide no indication of the need for RRT consultation. • Test-Taking Strategy: Note the strategic words "most appropriate." Visualize the health issues and signs and symptoms described with each client, and focus on the subject, the need for consultation with the RRT. • Review: prioritizing client care.

155. After a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. Which is the most appropriate nursing action? 1. Discuss the purposes and uses of seclusion 2. Obtain an informed, written consent from the client 3. Place the client in seclusion immediately as requested 4. Inform the client that seclusion has not been prescribed

155. Answer: 2 Rationale: While a client may request to be secluded or restrained, federal laws require the consent of the client, unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of involuntary seclusion and restraint is permitted only with the written prescription of a health care provider. Option 1 is not an appropriate intervention at this time. Option 3 fails to secure the appropriate client consent for voluntary seclusion. Option 4 does not address the client's expressed need for a controlled environment and may cause escalation of feelings. • Test-Taking Strategy: Note the strategic words "most appropriate." Focus on the subject, seclusion procedures. Recalling that a written informed consent is necessary unless it is an emergency situation will direct you to the correct option. • Review: informed consent and seclusion procedures.

156. The nurse manager is performing an inservice session on disaster preparedness and is discussing the phases of disaster management. Which phase encompasses actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of a disaster? 1. Response 2. Recovery 3. Mitigation 4. Preparedness

156. Answer: 3 Rationale: Mitigation encompasses actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of a disaster. This is followed by the preparedness phase, which encompasses planning for rescue, evacuation, and caring for disaster victims. Next is the response phase, which encompasses putting disaster planning services into action and the actions taken to save lives and prevent further damage. The recovery phase encompasses actions taken to return to a normal situation after the disaster. • Test-Taking Strategy: Note the subject, phases of disaster preparedness. Note the relationship between the words "prevent the occurrence of a disaster or reduce the damaging effects" in the query and the correct option. • Review: phases of disaster management.

157. The nurse employed in a mental health clinic is greeted by a neighbor who says, "How is Michelle doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I know you are really concerned, so I will share with you that she is doing much better than before." 2. "I'm not supposed to discuss this, but because you are her best friend I can tell you that she really has problems!" 3. "If you want to know about Michelle's progress, I suggest you ask her yourself. I'm not allowed to discuss this with you." 4. "I'm sorry and I'm sure you will understand, but as a nurse, I'm obligated to protect the privacy of all the clients I encounter. I cannot disclose any client information."

157. Answer: 4 Rationale: The nurse is required to maintain confidentiality about the client and his or her care. Both options 1 and 2 identify statements that do not maintain client confidentiality. In option 3, even though the nurse states that the nurse's responsibility is to maintain confidentiality, the nurse also confirms that the person is indeed a client of the clinic and so does breech confidentiality. • Test-Taking Strategy: Note the strategic words "most appropriate." Focus on the subject of the question, maintaining client confidentiality. This should assist in eliminating options 1, 2, and 3. • Review: ethical principles and confidentiality.

158. From the following list of nursing activities, select those that may be delegated to the licensed practical nurse or licensed vocational nurse (LPN/ LVN). Select all that apply. 1. Assessment 2. Urinary catheterization 3. Endotracheal suctioning 4. Intramuscular medication administration 5. Subcutaneous medication administration 6. Medication administration by intravenous push

158. Answer: 2, 3, 4, 5 Rationale: In general, an LPN or LVN can perform the tasks that an unlicensed assistive personnel can perform (skin care, range-of-motion exercises, grooming, ambulation, hygiene measures) as well as dressing changes, endotracheal suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramuscular, and some selected piggyback medications). Assessment and administration of intravenous push medications are responsibilities of the registered nurse. • Test-Taking Strategy: Focus on the subject, delegation to an LPN or LVN. Remember that assessment and administration of intravenous push medications are the responsibility of the registered nurse. • Review: delegation principles.

159. The nurse assigned to four clients reviews client data at the beginning of the shift. Which client data should be further assessed as the highest priority? 1. Hemoglobin 12.2 g/ dL 2. Potassium level 3.6 mEq/ L 3. Pulse oximetry reading 89% 4. Urine output 240 mL/ 8 hours

159. Answer: 3 Rationale: Priorities are classified as high, intermediate, and low. The pulse oximetry is below normal and indicates the highest priority. Inadequate oxygenation to tissues is life threatening. The hemoglobin level and the potassium level are within normal range, which are low priorities. The urine output reading is marginal; 240 mL in an 8-hour period would indicate adequate but low urine output, which is an intermediate priority. • Test-Taking Strategy: Note the strategic words "highest priority," and use the ABCs—airway, breathing, circulation—as well as knowledge regarding normal findings to direct you to the correct option. • Review: guidelines for prioritizing.

160. Which responsibilities for disaster preparedness in the United States are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA)? Select all that apply. 1. Provide monetary relief 2. Provide crisis counseling 3. Identify and train personnel 4. Deploy National Guard troops 5. Handle inquiries from families 6. Issue presidential declarations

160. Answer: 2, 3, 5 Rationale: In general, the ARC provides support to individuals involved in a disaster, while FEMA deals with regional responses to disasters such as providing monetary relief, deploying National Guard troops, and issuing presidential declarations. ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief including crisis counseling, operating shelters, and handling inquiries from the family. • Test-Taking Strategy: Focus on the subject, the role of the ARC and the role of FEMA. Noting that FEMA is a federal agency will assist in eliminating options 1, 4, and 6. • Review: disaster principles.

161. The community health nurse is preparing to teach "personal and family preparedness for disasters" to parents of school-age children. Identify the most appropriate item( s) needed in the event of a disaster that should be included in the teaching. Select all that apply. 1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses 5. Three-week supply of nonperishable food 6. Three-week supply of water (1 gallon per person per day)

161. Answer: 1, 2, 3, 4 Rationale: Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per person per day). Similarly, a 3-day supply of nonperishable food is recommended. A 3-week supply of water and food is unnecessary and not recommended. • Test-Taking Strategy: Note the strategic words "most appropriate." Focus on the subject, items for preparedness for disasters. When examining a list, work to categorize like items. In this instance, food and water would be grouped. Next, evaluate the reasonableness of amounts that are listed. A 3-week supply of food and water would be an extraordinary amount of materials to set aside and maintain. • Review: disaster planning.

162. A client with Alzheimer's dementia is being admitted to a long-term care facility. The client is widowed and previously lived at home alone. Which person would be acceptable to sign an advance directive, specifically with regard to resuscitative orders on behalf of this client? 1. The client 2. The social worker 3. The client's daughter 4. The health care provider

162. Answer: 3 Rationale: An advance directive is a written document recognized by state law that provides directions concerning the provision of care when a client is unable to make his or her own treatment choices; the two basic types of advance directives include living wills and durable powers of attorney. In terms of resuscitative orders, if the client is unable to make decisions for himself or herself, the power of attorney then makes these decisions. If a power of attorney had not been previously appointed by the client, the next of kin will make decisions with regard to health care for the client. Since the client has Alzheimer's dementia, option 1 is incorrect. Options 2 and 4 are incorrect because members of the health care team cannot make decisions for clients. • Test-Taking Strategy: Focus on the subject, and note that the client in the question has Alzheimer's dementia. Recalling the concept of durable power of attorney will assist in directing you to the correct option. • Review: advance directives.

163. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up? 1. Client with chronic kidney disease and a serum creatinine of 1.6 mg/ dL 2. Client with diabetes mellitus and a glycosylated hemoglobin A (HbA1c) of 7% 3. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/ mL 4. Client who is male and has anemia with a hemoglobin of 16.5 g/ dL and a hematocrit of 45%

163. Answer: 3 Rationale: The client with a history of heart failure with a BNP level of 140 pg/ mL requires follow-up. Levels above 100 pg/ mL indicate the presence of heart failure, and the higher the value the greater the degree of failure. The normal serum creatinine level is 0.6 to 1.3 mg/ dL. A serum creatinine of 1.6 mg/ dL for a client with chronic kidney disease is expected. An HbA1c level of 7% and below indicates good blood glucose control over a period of 3 to 4 months. The normal hemoglobin is 14 to 16.5 g/ dL and hematocrit is 42% to 52% for the male client. • Test-Taking Strategy: Note the strategic word "immediate." Also, note the subject, the finding that indicates the need for immediate follow-up. This subject indicates the need to select the option with the most concerning findings. Recalling normal values and the pathophysiology of the disorders in the options will direct you to option 3. • Review: normal laboratory values.

164. The nurse performs an admission assessment on an older client and suspects physical abuse. Which client is most at risk for abuse? 1. The older client who is independent with activities of daily living 2. The older client who attends many church activities and volunteers on a regular basis 3. The older client who is dependent on children to manage instrumental activities of daily living 4. The older client whose caregiver states, "I really enjoy spending so much time with my mother."

164. Answer: 3 Rationale: Abuse involves physical, emotional, or sexual abuse and also includes neglect or economic exploitation. Dependency on others in any way can result in caregiver stress. The older client who is dependent on children to manage instrumental activities of daily living is at an increased risk for abuse. Options 1, 2, and 4 do not indicate dependence or caregiver stress and therefore are incorrect. • Test-Taking Strategy: Note the strategic word "most." Focus on the subject, the older client most at risk for abuse. Noting the word "dependent" in option 3 will direct you to this option. • Review: abuse of the older client.

165. A client is involuntarily admitted to the mental health unit because of episodes of extremely violent behavior toward himself and others. The client is now demanding to be discharged from the hospital immediately and threatens to "break every window in my room" if stopped. The nurse tells the client he will not be allowed to leave and calls security to the unit. The client states, "This is false imprisonment. I'll sue!" Which represents the legal ramifications associated with the nurse's interventions? 1. This is false imprisonment and so the client has grounds to sue 2. The nurse is reacting responsibly, so there are no legal consequences 3. The nurse has failed to provide a therapeutic environment, and the client can sue 4. The nurse has failed to help deescalate the situation, but there are no legal consequences

165. Answer: 2 Rationale: False imprisonment is an act with the intent to confine a person to a specific area. If the client is involuntarily admitted or if the client has agreed to an evaluation before discharge, then the nurse's actions are reasonable. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital only if the client was voluntarily admitted and if there are no agency or legal policies for detaining the client. The client in this question was admitted involuntarily; therefore, option 1 is incorrect. Options 3 and 4 are incorrect because the nurse provides for a therapeutic and safe environment for the client and other clients by informing the client he cannot leave and by calling security. • Test-Taking Strategy: Focus on the subject, a client demanding discharge from the hospital. Noting the words "involuntary admitted" will direct you to the correct option. • Review: voluntary and involuntary admission.

167. An adolescent asks the nurse if she is of age to make an organ donation. The nurse should tell the adolescent that the individual must be at least which age to make an organ donation? 1. 13 2. 16 3. 18 4. 21

167. Answer: 3 Rationale: An individual who is at least 18 years of age may make an anatomical gift or organ donation. Therefore, options 1, 2, and 4 are incorrect. • Test-Taking Strategy: Focus on the subject, the legal age for making an organ donation. Remember that an individual who is at least 18 years of age may make an anatomical gift or organ donation. • Review: organ donation legal guidelines.

168. Two staff nurses have requested the same weekend as a vacation weekend. The nurse manager will need one of the two nurses to work the usual shifts. Which statement by the manager to the staff nurses would indicate the manager's use of information power? 1. "If neither one of you volunteers to work, I'll schedule you both for the weekend you've requested." 2. "Let's ask the staff to elect the person who is most deserving of having the requested weekend off." 3. "I'll review the scheduling records, including requests for time off for the past 3 years, to determine the history of outcomes for requests for time off in order to determine which nurse is most eligible for the weekend." 4. "One of the things that I have learned in nursing practice is that flexibility is essential. If one of you will volunteer to work the weekend so that the other staff nurse may use it for vacation, you'll be well-respected by your peers."

168. Answer: 3 Rationale: Option 3 is correct because the manager is using access to information from past requests to determine the person who is most eligible. Option 1 is incorrect because it suggests that both nurses will be "punished" by having to work the requested weekend. Option 2 is incorrect because the statement indicates the use of interpersonal power to make the decision. Option 4 is incorrect because it indicates a basis for the staff nurse to develop personal power. • Test-Taking Strategy: Focus on the subject, informational power. Note the relationship to this subject and the statement in the correct option. • Review: types of managerial power.

169. Which is an example of a client assault? 1. Taking photographs of a client without the client's consent 2. Administering an injection that the client refused to receive 3. Taking the client for an x-ray when the client refused consent 4. Threatening to administer a sedative to a client who is restless

169. Answer: 4 Rationale: An assault is any intentional threat to bring about harmful or offensive contact. No actual contact is necessary. Threatening to administer a sedative to a client who is restless is an example of assault. Option 1 is an example of invasion of privacy. Options 2 and 3 are examples of battery. • Test-Taking Strategy: Focus on the subject, assault. Note the relationship between the definition of assault (any intentional threat) and the correct option. • Review: ethical and legal principles.

170. Which best describes nursing standards of care? Select all that apply. 1. They are guidelines for nursing practice. 2. Nursing standards of care are defined in Nurse Practice Acts. 3. The law upholds the standards of care that the nurse must follow. 4. They are specific guidelines only for unlicensed assistive personnel. 5. They are used to measure nursing conduct in a malpractice lawsuit. 6. They are used to determine whether the nurse acted as any reasonably prudent nurse under the same or similar conditions.

170. Answer: 1, 2, 3, 5, 6 Rationale: Standards of care are guidelines for nursing practice. They are not specific guidelines only for unlicensed assistive personnel. Options 1, 2, 3, 5, and 6 are correct descriptions of standards of care. • Test-Taking Strategy: Focus on the subject, standards of care for nursing practice. Also eliminate option 4 because of the closed-ended word "only." • Review: nursing standards of care.

172. The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the nurse completes an incident report, calls the health care provider, and then notifies the nursing supervisor of the medication error. The nurse who administered the inaccurate medication dose understands which about the incident report? 1. Is a method of promoting quality care 2. Will result in temporary job suspension 3. Is reported to the State Board of Nursing 4. Will be a part of the client" s permanent medical record

172. Answer: 1 Rationale: Proper documentation of unusual occurrences, incidents, and accidents and the nursing actions taken as a result is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks. Based on the information provided in the question, the nurse's error will not result in suspension based on this act alone because the nurse acted prudently. The error and the situation presented in the question are not a reason for notifying the State Board of Nursing. The report is confidential and separate from the medical record. • Test-Taking Strategy: Focus on the subject, the purpose of incident reports. This will assist you in eliminating options 2, 3, and 4. Also note that the correct option is also the umbrella option. • Review: incident reports.

173. The nurse understands that which is accurate regarding the Occupational Safety and Health Administration (OSHA)? 1. Reports are not confidential. 2. A safe and conducive workplace must be provided by the employer. 3. An employee who reports unsafe working conditions can be retaliated against. 4. The board of nursing is notified only if nursing administration cannot handle the issue.

173. Answer: 2 Rationale: OSHA requires that employers provide a safe and conducive workplace for employees according to regulations. Employees can confidentially report working conditions that violate regulations. An employee who reports unsafe working conditions cannot be retaliated against by the employer. The board of nursing is notified in many instances depending on the circumstance, but not only if the nursing administration cannot handle the issue. Many times, outside authority is necessary to handle issues in the workplace. • Test-Taking Strategy: Note the subject of the question, mandated OSHA guidelines. Recalling that these guidelines relate to workplace safety will direct you to the correct option. • Review: Occupational Safety and Health Administration.

174. The nurse understands that use of advance directives is enforced by which authoritative body or act? 1. The Joint Commission 2. Patient Self-Determination Act 3. Health Portability and Accountability Act 4. Occupational Safety and Health Administration

174. Answer: 2 Rationale: The use of advanced directives (living wills and durable powers of attorney) is enforced by the Patient Self-Determination Act. The Patient Self-Determination Act is a law that indicates clients must be provided with information about their rights and identifies written directions about the care that they wish to receive in the event that they become incapacitated and are unable to make health care decisions. The Joint Commission is an accrediting body for health care agencies. The Health Portability and Accountability Act is a federal law that establishes standards for the privacy and security of health information and a standard for electronic data interchange of health information. The Occupational Safety and Health Administration requires that an employer provide a safe workplace for employees according to regulations. • Test-Taking Strategy: Focus on the subject, advance directives. Recalling the definition of advance directives and its relationship to the Patient Self Determination Act will direct you to the correct option. • Review: advance directives.

175. The nurse is caring for the assigned clients for the day. The nurse fulfills the wishes of three of the four clients, and due to time constraints is unable to fulfill the wishes of the fourth client. Which ethical principle has the nurse violated? 1. Justice 2. Fidelity 3. Veracity 4. Beneficence

175. Answer: 1 Rationale: Justice is defined as the equitable distribution of potential benefits and tasks determining the prescription in which clients should be cared for. If the nurse follows up on the needs of some assigned clients but not all, this principle has been violated. Fidelity refers to the duty to do what one has promised. Veracity is the obligation to tell the truth. Beneficence is the duty to do good to others and to maintain a balance between benefits and harms; paternalism is an undesirable outcome of beneficence, in which the health care provider decides what is best for the client and encourages the client to act against his or her own choices. • Test-Taking Strategy: Focus on the subject of the question, definitions of ethical principles, and what the question is asking. Relate the concept of justice to "fairness." • Review: ethical principles.

176. With regard to advance directives, which situation( s) identify an aspect of the nurse's role? Select all that apply. 1. Determining whether an advance directive exists upon admission 2. Signing as a prescriber or enforcer of the client's wishes on the advance directive 3. Ensuring that all health care workers caring for the client are aware of the code status 4. Ensuring that the health care provider is aware of the presence of an advance directive 5. Ensuring that the client has been provided with the necessary information to make the decision regarding life-saving measures

176. Answer: 1, 3, 4, 5 Rationale: With regard to advance directives, the nurse's role includes determining whether an advance directive exists upon admission and, if so, including it as part of the client's medical record. The nurse also should ensure that all health care workers for the client are aware of the client's code status. The nurse also should ensure that the health care provider is aware of the presence of an advance directive. If an advance directive does not exist, the nurse should ensure that the client has been provided with the necessary information to make the decision regarding life-saving measures and encourage the client to discuss these measures with the health care provider. The nurse cannot sign as a prescriber or enforcer of the client's wishes; this is the health care provider's responsibility. • Test-Taking Strategy: Focus on the subject, the nurse's role. Use knowledge of the nursing scope of practice with regard to advance directives to direct you to the correct options. • Review: advance directives.

202. The nurse working in the long-term care setting understands that special consents are required in which scenarios( s)? Select all that apply. 1. Use of restraints 2. Transferring units 3. Referral to a specialist 4. Photographing a client 5. Performing an autopsy 6. Donating organs after death

202. Answer: 1, 4, 5, 6 Rationale: Special consents are required for the use of restraints; photographing a client; performing an autopsy; and donating organs after death. Transferring units and referrals to specialists do not require special consent forms. • Test-Taking Strategy: Note the subject, special consents. Eliminate options 2 and 3, recalling that these actions do not require signing of informed consent forms. • Review: special consents.

177. The nurse who specializes in nursing informatics is providing a teaching session to staff nurses regarding electronic documentation. The nurse should include which instruction( s) as important guidelines to follow with regard to maintaining confidentiality of health records? Select all that apply. 1. Changing of personal passwords on a regular basis 2. Developing a password hint that is difficult to guess 3. Sharing access codes with authorized personnel only 4. Ensuring that accounts have been logged out when away from the computer 5. Granting access to printed records to client family members and friends only

177. Answer: 1, 2, 4 Rationale: In order to ensure confidentiality while using electronic documentation methods, passwords should be changed on a regular basis; password hints should be difficult to guess; access codes should not be shared with any other person; accounts should be logged out of when away from the computer; and printed documents should be given only to those specifically granted access by the client. In many institutions, a written release form with the client's signature is necessary to release forms. • Test-Taking Strategy: Focus on the subject, measures that ensure client confidentiality. Note that sharing access codes and granting access to printed records present a threat to client confidentiality. • Review: confidentiality and electronic documentation.

178. The nurse has filed an incident report after a client sustained a fall. The nurse should place the report in which location? 1. The client's medical record 2. The quality assurance team's mailbox 3. The nursing supervisor's locked mailbox 4. Outgoing mail to be sent to the health care provider's office

178. Answer: 3 Rationale: After completing an incident report, the most appropriate location to file it is in the nursing supervisor's locked mailbox. The nursing supervisor must review the report and file the appropriate reports per agency policy regarding the incident. An incident report is never placed in the client's medical record, and no reference to the report is made in the client's record. While the quality assurance team may use this information in the prevention of future incidences, it initially should be given to the nursing supervisor. The health care provider is notified of the incident, but a copy of the incident report does not need to be sent; the purpose of these reports is for the facility to review and analyze to determine how to improve quality of care within the facility. • Test-Taking Strategy: Focus on the subject, recalling the purpose of incident reports, and thinking about the channels of communication will direct you to the correct option. • Review: incident reports.

179. While riding the elevator to their assigned unit, two nurses are talking about a client who is hospitalized in the mental health unit. Which description( s) are accurate about confidentiality in this situation? Select all that apply. 1. The client's right to confidentiality does not apply to the mental health unit 2. Talking about clients in public places is a violation of the client's confidentiality 3. Talking about clients in public places can result in disciplinary action for the nurses 4. The client's right to confidentiality does not apply to the personal break time of employees 5. It is acceptable for the nurses to talk about the client because they are on the same treatment team

179. Answer: 2, 3 Rationale: While it is acceptable for the nurses on the same treatment team of a client to discuss the client's treatment, it is not appropriate to do so in an elevator or other public place. This can result in disciplinary action for those who violate the client's right in this manner. The client has a right to confidentiality regardless of the setting of the hospitalization. • Test-Taking Strategy: Eliminate options 1 and 4 because they are comparable or alike. From the remaining options, use guidelines related to client rights' to direct you to the correct options. Review: confidentiality.

180. A client just underwent a lung resection and has two chest tubes in place that are draining red fluid. The charge nurse should most appropriately assign which health care personnel to care for the client? 1. Student nurse 2. Outside agency nurse 3. Registered nurse (RN) 4. Licensed practical nurse (LPN)

180. Answer: 3 Rationale: An RN should be assigned to a postoperative client who underwent lung resection and has chest tubes in place. An LPN may be competent to measure chest drainage and to monitor client's vital signs, but because the client just had surgery it is best to assign the RN. A student nurse may or may not be competent to perform the care required. An agency RN may be competent but may not be familiar with unit practices and hospital policies and procedures. • Test-Taking Strategy: Note the strategic words "most appropriately." Focus on the data in the question, and note that the client just had a lung resection. This will direct you to the correct option. • Review: postoperative care.

181. The nurse understands that which is descriptive of client advocacy? 1. An advocate avoids letting personal values influence advocacy 2. An advocate acts on behalf of the client even without the client's permission to do so 3. An advocate does not speak up for a client if the action conflicts with personal beliefs 4. An advocate makes decisions for the client in such a way he or she believes the client would

181. Answer: 1 Rationale: A client advocate is defined as a person who speaks up for or acts on behalf of the client, protects the client's right to make his or her own decisions, and upholds the principle of fidelity. An advocate represents the client's viewpoints to others and avoids letting personal values influence advocacy. An advocate does not act on behalf of the client without the client's permission and does not make decisions for the client unless the client has clearly delineated a decision and wishes for it to be supported. • Test-Taking Strategy: Focus on the subject, client advocacy. Recalling the definition of an advocate and recalling that it is an ethical principle will assist you in eliminating options 2, 3, and 4. • Review: advocacy.

182. Which accurately describes the principle of respondent superior? 1. The employer is ultimately responsible for any negligent act of an employee that is within the employee's scope of responsibility 2. The employer is ultimately responsible for any negligent act of an employee, even if the act is outside the employee's scope of responsibility 3. The employee rather than the employer is ultimately responsible for any negligent act, even if the act is within the employee's scope of responsibility 4. The employee rather than the employer is ultimately responsible for any negligent act, even if the act is outside of the employee's scope of responsibility

182. Answer: 1 Rationale: Respondent superior indicates that the employer is held liable for any negligent act of an employee if the alleged negligent act occurred during the employment relationship and was within the scope of the employee's responsibility. Options 2, 3, and 4 are incorrect. • Test-Taking Strategy: Focus on the subject, the principle of respondent superior, and recall that the employer is responsible for a negligent act of the employee as long as it is within the employee's scope of responsibility. • Review: respondent superior.

183. The nursing instructor is conducting a teaching session regarding the role of a case manager. Which statement, if made by a student, indicates a need for further instruction? 1. "A case manager is a professional nurse." 2. "A case manager's involvement ceases after discharge." 3. "A case manager establishes a plan of care with the client." 4. "A case manager assumes responsibility for coordinating client care."

183. Answer: 2 Rationale: A case manager is a professional nurse who assumes responsibility for coordinating the client's care at admission and after discharge. The case manager establishes a plan of care with the client, coordinates any consultations and referrals, and facilitates discharge. A case manager's involvement does not cease after discharge, and the channel of communication remains open beyond discharge. Options 1, 3, and 4 are accurate descriptions of case management. • Test-Taking Strategy: Note the strategic words "need for further instruction." These words indicate a negative event query and the need to select the incorrect statement as the answer. Recalling that case management responsibilities extend beyond discharge will direct you to the correct option. • Review: case management.

184. The nursing instructor is conducting a teaching session on nursing care plans. Which statement, if made by a student, indicates a need for further instruction? 1. "A nursing care plan is a written guideline and communication tool." 2. "A nursing care plan involves members of the health care team only." 3. "A nursing care plan identifies the client's pertinent assessment data." 4. "A nursing care plan enhances continuity of care by identifying specific nursing actions."

184. Answer: 2 Rationale: A nursing care plan involves members of the health care team as well as the client and family, and short-and long-term goals are developed. A nursing care plan is a written guideline and communication tool that identifies the client's pertinent assessment data, problems and nursing diagnoses, goals, interventions, and expected outcomes. Care plans enhance continuity of care by identifying specific nursing actions necessary to achieve the goals of care. • Test-Taking Strategy: Note the strategic words "need for further instruction." These words indicate a negative event query and the need to select the incorrect statement as the answer. In addition, noting the closed-ended word "only" will assist in directing you to the correct option. • Review: nursing care plans.

185. The case manager is responsible for which aspect( s) of client care? Select all that apply. 1. Coordinating consultations and referrals 2. Delivering competent bedside client care 3. Establishing a plan of care with the client 4. Addressing client concerns and facilitating discharge 5. Supervising care provided by unlicensed assistive personnel (UAP)

185. Answer: 1, 3, 4 Rationale: A case manager is a professional nurse who assumes responsibility for coordinating the client's care at admission and after discharge. Responsibilities of the case manager include coordinating consultations and referrals; establishing a plan of care with the client; and addressing client concerns and facilitating discharge. Delivering competent bedside care and supervising care provided by a UAP are responsibilities of the primary nurse. • Test-Taking Strategy: Note the subject, responsibilities of the case manager. Recalling that the case manager does not typically provide bedside care will assist you in eliminating the incorrect options. • Review: responsibilities of the case manager.

186. The new nursing graduate understands that nursing care plans enhance continuity of client care by serving as a written guideline and ensuring communication by identifying which item? 1. Short-term goals delineated for the hospital stay only 2. Nursing actions necessary to achieve the goals of care 3. The similarity between nursing actions and medical actions 4. The mode of communication between interdisciplinary care teams

186. Answer: 2 Rationale: A nursing care plan is a written guideline and communication tool that identifies the client's pertinent assessment data, problems and nursing diagnoses, interventions, and expected outcomes. The plan enhances continuity of client care by identifying the nursing actions necessary to achieve the goals of care. Short-term and long-term goals are identified as the client and family are involved in developing the plan of care. Nursing care plans do not identify the similarity between nursing and medical actions involved in client care. This tool does not serve as a mode of communication between interdisciplinary care teams, although it can be used as a reference at care plan coordination meetings. • Test-Taking Strategy: Note the subject, the purpose of the nursing care plan. Begin by eliminating option 1, noting the closed-ended word "only." Next, eliminate options 3 and 4 because they are comparable or alike and identify integration between nursing and other health care disciplines. • Review: nursing care plans.

187. The nurse newly employed in the acute care setting understands that relationship-based nursing is focused on which specific purpose? 1. Keeping the nurse at the bedside 2. Accountability for specific tasks 3. Caring for clients close by geographically 4. Delegated tasks rather than the total client

187. Answer: 1 Rationale: Relationship-based nursing focuses on keeping the nurse at the bedside, actively involved in client care, while planning goal-directed, individualized client care. Team nursing is focused on accountability for specific tasks. Modular nursing is focused on caring for clients who are close by geographically. Functional nursing and team nursing focus on delegated tasks rather than the total client. • Test-Taking Strategy: Focus on the subject, relationship-based nursing. Note the similarity between the word "relationship" and the correct option. • Review: relationship-based nursing.

188. The newly-employed nurse is attending orientation and is learning about accountability. Which description is accurate with regard to this professional responsibility? 1. The individual ensures that mistakes are never associated with care provided. 2. The individual has an obligation to the client and is answerable for his or her actions. 3. The individual does not admit to fault and focuses on avoidance of malpractice suits. 4. The individual assumes responsibilities within and outside of his or her scope of practice.

188. Answer: 2 Rationale: Accountability is the process in which individuals have an obligation (or duty) to act and are answerable for their actions. The individual admits to mistakes rather than blaming others and evaluates the outcomes of one's own actions. The individual assumes responsibilities within his or her scope of practice (not outside) and does not assume responsibility for which competence has not been achieved. • Test-Taking Strategy: Note the subject, the professional responsibility of accountability. Eliminate options 1 and 3 because they are comparable or alike. Eliminate option 4 because of the word "outside." • Review: accountability.

191. The nurse manager has adopted a leadership theory that focuses on maintaining a balance between tension and order to prevent an unstable environment and promote creativity. What leadership theory is the manager using? 1. Servant 2. Quantum 3. Relational 4. Charismatic

191. Answer: 2 Rationale: The quantum leadership theory focuses on maintaining a balance between tension and order to prevent an unstable environment and promote creativity. Servant theory is based on the desire to serve others; the leader emerges when another's needs assumes priority. The relational theory is based on collaboration and teamwork. The charismatic theory is based on personal beliefs and characteristics. • Test-Taking Strategy: Note the subject, maintaining a balance between tension and order. Note the relationship between the description of the theory in the question and the correct option. In addition, recall that the quantum theory is based on concepts of the chaos theory. • Review: theories of leadership and management.

192. The nurse manager has adopted a leadership theory that is based on the belief that several individuals share the responsibility for achieving the health care agency's goals. What leadership theory is the manager using? 1. Shared 2. Servant 3. Transactional 4. Transformational

192. Answer: 1 Rationale: The shared leadership theory is based on the belief that several individuals share the responsibility for achieving the health care agency's goals. Servant theory is based on the desire to serve others; the leader emerges when another's needs assumes priority. Transactional theory is based on the principles of social-exchange theory. Transformational theory is based on the individual's commitment to the health care agency's vision and focuses on promoting change. • Test-Taking Strategy: Note the subject, a theory based on the belief of sharing responsibilities. Note the relationship between the description of the theory in the question and the correct option. • Review: theories of leadership and management.

193. The nurse manager working in the intensive care unit (ICU) has adopted a bureaucratic leadership style. Which description is characteristic of this leadership style? 1. Decision making is left to the group, and the manager provides little feedback. 2. Leadership is derived from the needs of the group and the tasks to be achieved. 3. The manager relies on organizational policies and procedures for decision making. 4. The manager dominates the group and commands rather than seeks input from the group.

193. Answer: 3 Rationale: The bureaucratic leadership style is used when the manager believes that individuals are motivated by external forces. The manager relies on organizational policies and procedures for decision making. A laissez-faire leadership style assumes a passive, nondirective, inactive approach and relinquishes part or all of the responsibilities to members of the group, and the manager provides little to no feedback. The situational leadership style uses a combination of styles based on the current circumstances and events. Leadership is derived from the needs of the group and the tasks to be achieved. The autocratic leadership style is focused on maintaining strong control, making all decisions, and addressing all problems. The manager dominates the group and commands rather than seeks input from the group. • Test-Taking Strategy: Focus the subject, a bureaucratic leadership style. Note the relationship between the subject and the description of the leadership style in the correct option. • Review: leader and manager approaches.

194. The nurse manager is attending a session at a conference on effective leader and management behaviors. The manager understands that which are characteristic of these effective behaviors? Select all that apply. 1. Motivates employees to achieve goals 2. Treats employees as unique individuals 3. Inspires employees and stimulates critical thinking 4. Shows employees how to always think about problems in the same way 5. Remains distant from employees and encourages independence from the manager

194. Answer: 1, 2, 3 Rationale: Effective leader and manager behaviors include the following: motivates employees to achieve goals; treats employees as unique individuals; inspires employees and stimulates critical thinking; shows employees how to think of old problems in new ways; is visible to employees; is flexible; and provides guidance, assistance, and feedback; and communicates a vision, establishes trust, and empowers employees. • Test-Taking Strategy: Note the subject, effective leader and manager behaviors. Eliminate option 4 because this option does not inspire critical thinking and creativity. Eliminate option 5 because leaders and managers should not be distant from their employees. • Review: effective leader and manager behaviors.

195. The nurse manager is exercising a type of power on the nursing unit that is based on the ability to punish an employee. Which type of power is the manager utilizing? 1. Expert 2. Reward 3. Referent 4. Coercive

195. Answer: 4 Rationale: Coercive power is based on the ability to punish an employee. Expert power is based on having an expert knowledge base and skill level. Reward power is based on the ability to provide incentives. Referent power is based on attraction. • Test-Taking Strategy: Focus on the subject, types of power. Note the relationship between the subject of the question and the correct option (coercive and the ability to punish). • Review: types of power.

196. The nurse manager is exercising a type of power on the nursing unit that is based on a position in the organization. Which type of power is the manager utilizing? 1. Reward 2. Personal 3. Legitimate 4. Informational

196. Answer: 3 Rationale: Legitimate power is based on a position in society, such as the organization. Reward power is based on the ability to provide incentives. Personal power is derived from a high degree of self-confidence. Informational power is when one person provides explanations of why another should behave in a certain way. • Test-Taking Strategy: Focus on the subject, types of power. Note the relationship between the subject of the question and the correct option (position in society and legitimate). • Review: types of power.

197. The nurse manager is attending an in-service session on policies, procedures, and protocols of an organization. Which description is accurate regarding the meaning of protocols? 1. They are based on policy and define methods for specific tasks. 2. They are guidelines that define an organization's standpoint on courses of action. 3. They prescribe a specific course of action for a specific type of client or problem. 4. They are measureable activities specific to the development of designated services.

197. Answer: 3 Rationale: Protocols prescribe a specific course of action for a specific type of client or problem. Procedures are based on policy and define methods for specific tasks. Policies are guidelines that define an organization's standpoint on courses of action. Goals and objectives are measureable activities specific to the development of designated services. • Test-Taking Strategy: Note the subject, the meaning of protocols. Recall that protocols are used in specific circumstances, prescribe a course of action, and are based on policies and procedures. • Review: policies, procedures, and protocols.

198. Evidenced-based practice requires that a nurse base nursing practice on evidence from which resource? 1. Health care magazines 2. Clinical research studies 3. Government recommendations 4. Health care provider instruction

198. Answer: 2 Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. Evidence-based practice requires that the nurse base nursing practice on evidence from clinical research studies. The nurse should also be alert to clinical issues that warrant investigation and develop a researchable problem about the issue. Options 1, 3, and 4 are incorrect. • Test-Taking Strategy: Note the subject, evidence-based practice. Recalling that clinical research studies are a rigorous form of research related to nursing practice will assist in directing you to the correct option. • Review: evidence-based practice.

201. The nurse manager is in the process of implementing a new method of intake and output documentation on the nursing unit. The manager determines that resistance to change is present if which is noted? 1. Fear and habit are not an issue for staff 2. Employees exhibit no threats to satisfying basic needs 3. There are similar beliefs and values regarding change among staff 4. Staff feel that secondary gains are associated with the current method

201. Answer: 4 Rationale: There are many reasons for resistance to change, including fear (one fears failure or has fear of the unknown); habit (routine, set behaviors are often hard to change); dissimilar beliefs and values (differences can impede positive change); there are threats to satisfying basic needs (change may be perceived as a threat to self-esteem, security, or survival); and secondary gains are associated with the current method (benefits or payoff are present, so there is no incentive to change). • Test-Taking Strategy: Note the subject, resistance to change. Note that the correct option is the only one that could cause a potential resistance to change and the staff wanting to remain with the current method of documenting. • Review: resistance to change.

203. The nurse understands that clients who are mentally or emotionally incompetent are unable to sign informed consents for themselves. Which condition( s) indicate that a client is mentally or emotionally incompetent? Select all that apply. 1. Unconscious 2. Chronic dementia 3. Declared incompetent 4. Younger than 18 years of age 5. Under the influence of chemical agents

203. Answer: 1, 2, 3, 5 Rationale: Clients who are mentally or emotionally incompetent include: a client who is unconscious; a client with chronic dementia or other mental deficiency that impairs thought processes and ability to make decisions; a client who has been declared incompetent; and a client who is under the influence of chemical agents such as alcohol, drugs, or certain medications. While there are specific procedures according to the state for minors younger than 18 years of age, they are not considered mentally or emotionally incompetent based on age alone. • Test-Taking Strategy: Note the subject, the client who is mentally or emotionally incompetent, and therefore cannot sign informed consent forms. Eliminate option 4 because this option refers to age rather than cognitive functioning. • Review: informed consent procedures.

204. The nurse is signing as a witness on an informed consent form for a client who is undergoing surgery. The nurse understands that in most states, signing as a witness indicates which condition? 1. Signing as a witness to the client's signature 2. Signing as confirmation of the client's understanding of the procedure 3. Signing as confirmation of the client's understanding of risks and benefits 4. Signing as confirmation that all of the client's questions have been answered

204. Answer: 1 Rationale: In most states, when a nurse is involved in the informed consent process, the nurse is witnessing only the signature of the client on the informed consent form. The nurse should not sign as confirmation of the client's understanding of the procedure, the client's understanding of the risks and benefits, or that all of the client's questions have been answered. This is the responsibility of the surgeon and/ or health care provider. • Test-Taking Strategy: Focus on the subject, the nurse's signature on informed consent forms. Note the relationship between "witness" in the query and the correct option. • Review: informed consent procedures.

205. The registered nurse (RN) is delegating the task of respiratory suctioning to the licensed practical nurse (LPN). The RN must be familiar with which requirement( s) before delegation? Select all that apply. 1. Experience of the LPN 2. State nurse practice act 3. Job description of the LPN 4. Scope of practice of the LPN 5. Disciplinary record of the LPN

205. Answer: 1, 2, 3, 4 Rationale: Before delegation, the RN must be familiar with the LPN's experience, job description, scope of practice, the state nurse practice act, and the policy and procedures of the agency. The disciplinary record of the LPN is not necessary knowledge for delegation. • Test-Taking Strategy: Focus on the subject, principles of delegation. While the disciplinary record of nurses is public knowledge, it is not required for delegation procedures. • Review: delegation.

206. The registered nurse (RN) understands that, in general, certain invasive tasks can be delegated to which member of the health care team? 1. Ancillary personnel 2. Any health care provider (HCP) 3. Licensed practical nurse (LPN) 4. Unlicensed assistive personnel (UAP)

206. Answer: 3 Rationale: In general, the RN can delegate certain invasive tasks, such as dressing changes, suctioning, urinary catheterization, and medication administration (according to the state and agency policy), to LPNs. Ancillary personnel (e.g., maintenance, housekeeping) are not typically involved in direct client care. UAP can perform noninvasive tasks in the care of clients. The RN does not delegate to any HCP. • Test-Taking Strategy: Focus on the subject, invasive tasks and delegation. Eliminate option 2 first because the nurse does not delegate to any HCP. For the remaining options, note the word "invasive." This will direct you to the correct option. Recall that LPNs can perform certain invasive procedures in the care of assigned clients. • Review: delegation.

207. Which legal body primarily defines which aspects of care can be delegated and which aspects should be performed by the registered nurse (RN)? 1. Agency guidelines 2. The nurse practice act 3. Third-party consultants 4. Agency procedures and protocols

207. Answer: 2 Rationale: The nurse practice act and any practice limitations are the primary legal bodies that define which aspects of care can be delegated and which must be performed by an RN. Agency guidelines, third-party consultants, and agency procedures and protocols are not legal bodies responsible for this aspect of care. • Test-Taking Strategy: Note the subject, the legal body that defines delegation guidelines. Recall that the nurse practice act is a legal document within each state and defines this task. Also note that options 1 and 4 are comparable or alike and identify agency guidelines. Third-party consultants do not define delegation activities. • Review: the nurse practice act and delegation.

209. The registered nurse (RN) delegates the task of a midstream clean-catch urine specimen collection to the unlicensed assistive personnel (UAP). The nurse determines that the UAP has completed the task by the agreed-upon deadline. What should the RN do next? 1. Evaluate the outcome of the task 2. Determine the degree of supervision required 3. Have the UAP sign the laboratory requisition form 4. Provide feedback to the UAP regarding performance

209. Answer: 1 Rationale: When delegating a task to another member of the health care team, the RN should first be sure he or she is familiar with the experience of the delegatees, scopes of practice, job descriptions, agency policies and procedures, and the state nurse practice act. The RN should provide clear directions about the task and ensure that the delegatee understands the expectations. Then, the RN should determine the degree of supervision required. The RN should provide the delegatee with the authority to complete the task and provide a deadline for task completion. Next, the RN should evaluate the outcome of the task that has been delegated. Lastly, the RN should provide feedback to the UAP regarding performance. • Test-Taking Strategy: Note the strategic word "next." Think about the process of delegating a transferrable task to another member of the health care team to answer correctly. • Review: delegation.

211. When planning client assignments and delegating tasks, the registered nurse (RN) should take which action when communicating with members of the health care team? 1. Communicate a feeling of confidence 2. Provide feedback when it is convenient 3. Assign clients to different members regularly 4. Delegate tasks to delegatees with little experience

211. Answer: 1 Rationale: When communicating with members of the health care team with regard to assignment-making and delegating, the RN should communicate a feeling of confidence. The RN should provide timely feedback on completed tasks. In order to provide for continuity of care, the RN should assign clients to the same team members if possible. The RN should delegate tasks to delegatees and ensure comfort and experience in performing the task. • Test-Taking Strategy: Focus on the subject, assignment-making and delegation. Recalling that it is necessary to display confidence in delegatees will assist in directing you to the correct option. • Review: assignments and delegation.

212. The nurse understands that in order to effectively use concepts of time management, which skills need to be utilized? 1. Performing activities one at a time 2. Documentation at the end of the workday 3. Addressing all nonessential activities as they arise 4. Deciding on the most important tasks to complete first

212. Answer: 4 Rationale: Principles of time management include deciding on the most important tasks to complete first, documentation throughout the day as tasks are completed, combining as many activities as possible and anticipating the days' activities, and avoiding interruptions associated with nonessential activities. • Test-Taking Strategy: Note the strategic word "effectively." Also note the subject, time management. Use principles of prioritization to direct you to the correct option. • Review: time management.

213. The nurse who is utilizing concepts of time management understands the importance of which action to ensure effectiveness of this strategy? 1. Anticipate resource needs 2. Use health care agency resources wisely 3. Evaluate each strategy used at the end of the day 4. Gather necessary supplies before beginning a task

213. Answer: 3 Rationale: To ensure effectiveness of time management strategies, the nurse should evaluate each strategy used at the end of the day. Anticipating resource needs, using health care agency resources wisely, and gathering necessary supplies before beginning a task are all associated with time management, but are not related to the subject of ensuring effectiveness of strategies. • Test-Taking Strategy: Note the strategic word "effectiveness," and focus on the subject, time management. Note that the correct option is the only option that addresses ensuring effectiveness of time management strategies. • Review: time management.

214. The nurse is using concepts of time management to organize the workday. Which action will assist the nurse to effectively implement time management strategies? 1. Complete nonessential activities first to reduce interruptions 2. Plan the day so that all time is accounted for in task completion 3. Identify tasks that must be completed within a specific time frame 4. Assist others in the completion of their assigned tasks when asked

214. Answer: 3 Rationale: In order to effectively use time management strategies, the nurse should identify tasks that must be completed within a specific time frame. The nurse should complete essential tasks before focusing on nonessential tasks. Additionally, the nurse should plan the day so that there is time allowed for unplanned interruptions. The nurse should complete his or her own tasks first before assisting others, unless it is an emergency situation. • Test-Taking Strategy: Note the strategic word "effectively." Eliminate option 1, noting the word "nonessential." Next, eliminate option 2 because of the closed-ended word "all." From the remaining options, recall that assisting others should be done once the assigned tasks are completed. • Review: time management.

215. The nurse is attending an inservice on ethical codes. The instructor of the class determines that the nurse understands ethical codes if which statement is made by the nurse? 1. "Ethical codes are legally binding." 2. "Ethical codes only apply in certain scenarios." 3. "They provide broad principles for evaluating care." 4. "They do not need to be abided by in all client encounters."

215. Answer: 3 Rationale: Ethical codes provide broad principles for determining and evaluating care. Ethical codes are not legally binding, but the board of nursing has the authority in most states to reprimand nurses for unprofessional conduct that results from violation of ethical codes. Ethical codes apply in all client encounters and all scenarios. • Test-Taking Strategy: Eliminate options 2 and 4 because they are comparable or alike. From the remaining options, recall that ethical codes are not legally binding to assist in eliminating option 1. • Review: ethical codes.

217. The nurse understands that the central concept within the ethical principle of justice is identified by which description? 1. To remain truthful at all times 2. The obligation to cause no harm 3. The order in which clients are cared for 4. To maintain a balance between benefits and harms

217. Answer: 3 Rationale: Justice is the equitable distribution of potential benefits and tasks determining the order in which clients should be cared for. To remain truthful at all times is central to the ethical principle of veracity. The obligation to cause no harm is associated with nonmaleficence. To maintain a balance between benefits and harms is associated with beneficence. • Test-Taking Strategy: Note the subject, the ethical principle of justice. Note the relationship between the subject and the correct option. Additionally, associate this ethical principle with fairness. • Review: justice and other ethical principles.

220. Which type of law is concerned with enforcement of agreements among private individuals? 1. Tort 2. Civil 3. Criminal 4. Contract

220. Answer: 4 Rationale: Contract law is concerned with enforcement of agreements among private individuals. Tort law is a civil wrong, other than a breach in contract, in which the law allows the injured person to seek damages from a person who caused the injury. Civil law is concerned with relationships among persons and with the protection of a person's rights. Violation may cause harm to an individual or property, but no grave threat to society exists. Criminal law is concerned with relationships between individuals and governments, and with acts that threaten society and its order; a crime is an offense against society that violates a law and is defined as a misdemeanor (less serious nature) or felony (serious nature). • Test-Taking Strategy: Note the subject, the type of law concerned with agreements among private individuals. Note the relationship between the subject and the correct option. • Review: types of law.

222. Which are example( s) of a negligent act? Select all that apply. 1. Medication errors resulting in injury 2. Failure to monitor an intravenous flow rate resulting in injury 3. A decline in a client's condition resulting in a longer hospital stay 4. A fall that occurs as a result of failure to provide safety measures to a client 5. Failure to report a change in a client's condition to the health care provider (HCP)

222. Answer: 1, 2, 4, 5 Rationale: A negligent act is one that constitutes conduct that falls below the standard of care. It is a failure to meet a client's needs either willfully or by omission or failure to act. Therefore, options 1, 2, 4, and 5 are correct. A decline in a client's condition resulting in a longer hospital stay is not considered a result of a negligent act unless there was something specifically that the nurse did to cause the change in condition. • Test-Taking Strategy: Note the subject, negligent acts. Recall that in order for a negligent act to be constituted, the change in client condition must be a direct result from an action or lack thereof on the part of the nurse. • Review: negligence.

223. The new nursing graduate employed in the acute care setting asks experienced nurses about professional liability insurance. Which most appropriate response should the experienced nurse make to the graduate? 1. "It is really expensive and unnecessary." 2. "It will provide protection to you as an individual." 3. "You are covered under the hospital's insurance policy." 4. "I don't have it and have never found it to be necessary."

223. Answer: 2 Rationale: Professional liability insurance is required for protection against malpractice lawsuits. While the employing agency usually does provide protection to the health care workers, it is necessary for the nurse to purchase his/ her own in order for protection to be provided as an individual and to allow for an attorney's presence who only has the nurse's interests in mind. Options 1, 3, and 4 are incorrect. • Test-Taking Strategy: Note the strategic words "most appropriate." Recall that it is advisable for nurses to have their own professional liability insurance in order to answer this question correctly. • Review: professional liability insurance.

226. The nurse is preparing a discharge teaching plan for a client who is going home following a chronic obstructive pulmonary disease (COPD) exacerbation. In teaching the client, which step should the nurse take first? 1. Determine the client's immediate learning needs 2. Determine what the client perceives as important 3. Review the learning objectives established for the client 4. Assess the client's anxiety level and the amount of time available to teach

226. Answer: 1 Rationale: When preparing to teach a client, the first action is to determine the client's immediate learning needs. The nurse should then review the learning objectives established for the client. Next, the nurse should determine what the client perceives as important. Lastly, the nurse should assess the client's anxiety level and the amount of time available to teach. • Test-Taking Strategy: Note the strategic word "first." Determining the client's immediate learning needs is the first step in preparing to teach a client in order for teaching to be effective. • Review: setting priorities for client teaching.

228. When caring for a group of clients, the nurse considers which priority factor( s) in order to determine which client to care for first? Select all that apply. 1. Complexity of illness 2. Stability of condition 3. Basic needs of the client 4. Client feelings regarding care 5. Time required for care delivery

228. Answer: 1, 2, 3 Rationale: When determining which client to care for first, the priority factors to consider include the complexity of the illness, the stability of the condition, and the basic needs of the client. While time required for care delivery and client feelings are a consideration, the nurse should remember that physiological needs are the priority. • Test-Taking Strategy: Note the strategic word "first." Use Maslow's Hierarchy of Needs theory in order to answer this question correctly. • Review: guidelines for prioritizing.