Leadership Practice 2019 A
A nurse manager is teaching about confidentiality requirements to the staff...
"Change-of-shift report can be given at the client's bedside." Change-of-shift report is often given at the client's bedside to help protect the client's privacy. This allows the client to be involved with their care. The nurse should avoid giving report in public areas, such as in the hallway.
Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel...
"Check the urinary output at 1100 for John Doe and report it to me immediately." This instruction follows the Five Rights of Delegation by including the requirements for right direction/communication: the data to collect, client-specific information, a timeline for collection, and the expectation for communicating the findings back to the nurse.
A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and not actually in distress.
"Clients are the experts on their own health." This response is appropriate because it indicates the nurse understands that the client's report is the best indicator of pain and is not making any assumptions.
A nurse on a mental health unit is teaching a newly licensed nurse about client rights...
"Clients on a mental health unit can refuse their medications." Regardless of the type of health care facility or admission status, clients maintain the right to refuse medications.
An assistive personnel tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent...
"I delegate tasks to personnel based on their job descriptions." This response addresses the AP's concerns and provides clear information about the charge nurse's responsibility when delegating tasks.
A nurse if caring for a 19-year-old client who has just been informed that their cancer has metastasized...
"I will gather information about palliative care for you."
A nurse is receiving report from the assistive personnel assigned to the nurse's group of clients...
"The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void."
A nurse is caring for a client who is hospitalized and has expressive aphasia...
"This is a procedure that does not require written informed consent." The client does not need to sign an informed consent form for insertion of an indwelling urinary catheter. The client gives implied consent by complying with the procedure.
A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge...
"Your case manager will coordinate the resources you will need." A case manager coordinates a client's care, including resources for home care.
A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?
A client who had a right above-the-knee amputation 24 hr ago A nurse from a medical unit can care for this client because the surgical dressing is usually left in place for 48 to 72 hr, so the residual limb does not require special care at this time.
A nurse is caring for four clients...
A client who has a femur fracture and reports feeling shortness of breath When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is a client who has a femur fracture and reports feeling short of breath. Clients who have a fracture can develop a deep-vein thrombosis, which can lead to pulmonary embolism.
A nurse in an emergency department is admitting clients following an earthquake...
A client who has a sucking chest wound A client who has a sucking chest wound has an immediate threat to life and requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend the provider evaluate this client first.
A nurse on a medical-surgical unit is caring for four clients...
A client who has peripheral vascular disease and has an absent pulse in the right foot When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is an absent pulse, which indicates no blood flow to the extremity.
A charge nurse is supervising the care of several clients...
A nurse is photocopying their assigned client's diagnostic test results
A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness...
Advise the client to install grab bars in the bathroom at home The nurse should advise the client to install grab bars in the bathroom at home to reduce the risk for falls.
A nurse is caring for a client who is scheduled for outpatient surgery...
Ask the client to explain the procedure that is being performed The nurse should ask the client to explain the procedure that is being performed. This allows the nurse to verify the client's understanding of the information provided by the provider prior to witnessing the client's signature on the consent form.
A client on a general surgical unit tells a nurse that staff members are not answering the call light promptly...
Ask the client to verbalize their expectations The first action the nurse should take using the nursing process is to assess; therefore, the first action the nurse should take is to assess the client's feelings and clarify expectations.
A nurse receives notification of a fire on the unit...
Assist clients who are in immediate danger to a safe location The greatest risk to clients is injury from the fire. Therefore, the first action the nurse should take is to move clients who are in immediate danger to a safe location. RACE
A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take?
Assist in weighing the options involved in the decision Ethics committees are members of the interprofessional team who assist with problem solving related to ethical dilemmas. The ethics committee examines all of the facts and provides support for the clients and caregivers.
A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility...
Compare data from clients' records regarding skin integrity with established criteria
A nurse is assigning care for four clients...
Determine a client's intake and output
A charge nurse is leading a committee that is revising the policy for client discharge...
Determine goals and objectives According to evidence-based practice, the nurse attempting to make a change or revision to a policy should first develop the initial plan and then determine goals and objectives. Objectives define strategies or implementation steps to attain the identified goals.
A nurse is caring for a client who is recovering from a stroke...
Discuss the client's concerns about having the surgery The nurse should ask the client relevant questions to determine their concerns regarding having the surgery. By asking relevant, open-ended questions, the nurse can help the client clarify their thoughts and feelings about the surgery. The nurse can then relay these concerns to the provider for further discussion if needed.
A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do...
Discuss the client's feelings about the procedure The nurse should encourage the client to discuss any feelings or concerns about the procedure.
Two nurses on a unit each contend that the other is not doing a fair share of work...
Explore alternative solutions to address unit workflow with the nurses Exploring alternative solutions will allow the nurses to collaborate, which creates a higher probability that the nurses will reach a successful resolution.
A charge nurse recognizes a trend of poor attendance at monthly staff meetings...
Explore the reasons that staff are not attending meetings According to evidence-based practice, the nurse should first identify the reasons that staff are not attending the meetings. This allows the nurse to address the specific problems identified by the staff.
A nurse is caring for a client who requests pain medication...
Fidelity The nurse is demonstrating fidelity by returning to the client's room with the medication in a timely manner. Fidelity is an ethical principle in which the nurse's actions are taken to display loyalty and keep a promise made to the client.
A charge nurse observes that a staff nurse's behavior has changed over the past few weeks...
Frequent use of restroom Frequent use of the restroom can indicate that the nurse might be working while impaired. Other indications can include frequent errors, mood swings, inability to focus, and excessive wasting of controlled substances.
A charge nurse is observing a newly licensed nurse's use of time-management skills...
Groups tasks that are in the same location The newly licensed nurse should group tasks that are in the same location to effectively use time. This prevents the nurse from going back and forth from one area to another. This action promotes effective time-management skills.
A nurse is planning the discharge of a newborn who requires apnea monitoring at home...
Home health A home health agency can provide nurses who will visit the home and help the guardian learn necessary skills, as well as assess the progress of the infant.
A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries...
Identify stable clients for transfer to a surgical unit
A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?
Inform the assistive personnel of the client's weight-bearing status Assistive personnel can assist clients with ambulation in most cases with appropriate delegation from the nurse. The nurse should inform the AP of postoperative prescriptions for weight-bearing as part of safe care delegation.
A nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?
Inform the client of the consequences of refusing the medication The nurse should inform the client of the consequences of refusing the medication. It is the client's right to decide whether to take the medication. If the client still refuses after receiving further information, the nurse should waste the medication and document the occurrence in the client's medical record.
A nurse manager needs to address an increased rate of client medication errors...
Inform the staff of the penalties that can result from medication errors The nurse manager is using penalties to promote behavior change; this is characteristic of authoritarian leadership.
A nurse is providing prep teaching for a client who is scheduled for a total knee arthroplasty...
Interpreter
A nurse manager is duding client charts and identifies an increase in ventilator-associated pneumonia...
Notify the quality improvement team The nurse should report any unusual occurrences or trends, such as VAP within the unit, to the quality improvement team. The quality improvement team will analyze and evaluate the data to implement needed changes.
A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hr...
Obtain the client's serum potassium level Because vomiting and diarrhea contribute to the loss of potassium through body fluids, the greatest risk to this client is life-threatening cardiac dysrhythmias as a result of hypokalemia; therefore, the nurse should identify that the priority assessment is the client's serum potassium level.
A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes...
Occupational Therapist The nurse should recommend a referral to an occupational therapist for a client who has osteoarthritis and reports difficulty with ADLs, such as buttoning clothing. Occupational therapy can assist the client with exercises to help the client complete these tasks.
A nurse manager finds that there has been an increase in UTIs on the unit...
Perform a chart review to gather data about the clients who developed infections The first action the nurse manager should take when using the nursing process is to assess. The nurse should conduct a chart audit to gain important information about the factors responsible for the increased incidences of infection.
A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter...
Pick up the first sterile glove by grasping the folded cuff edge
A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplants...
Place clients in positive pressure airflow rooms The nurse should place a client who requires protective environment precautions following a stem cell transplant in a private, positive-pressure airflow room. The room air is filtered through a HEPA filter and the airflow rate is set at more than 12 air exchanges each hour.
A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment...
Place the client in a dorsal recumbent position for the examination To prepare the client for a routine abdominal assessment, the nurse should place the client in a dorsal recumbent or supine position and ensure that the client relaxes her abdominal muscles.
A home health nurse is planning her daily visits and receives laboratory results for four adult clients...
Platelets 100,000/mm^3 A client who has a platelet count of 100,000/mm3 is unstable because this value is below the expected reference range of 150,000 to 400,000/mm3, which places the client at risk for bleeding; therefore, the nurse should visit this client first.
A charge nurse is planning client care assignments for a unit to an LPN.
Provide an enteral feeding to a client who has Crohn's disease Administration of an enteral feeding is within the scope of practice of an LPN; therefore, it is appropriate for the charge nurse to assign this task to an LPN.
A hospice nurse is planning care for a client who does not have advance directives...
Provide the clients with information about advance directives
A nurse is reviewing safe use of a wheelchair with a group of assistive personnel...
Raise the footplates of the wheelchair before transferring the client The nurse should raise the footplates of the wheelchair before transferring the client to prevent injury. The nurse should lock the brakes on both wheels when transferring the client. The nurse should back the wheelchair into the elevator with the rear wheels first to prevent injury. The nurse should stand between the wheelchair and the bottom of the incline to provide better control of the wheelchair by keeping weight close to the body. This position allows the nurse to use their arms and legs rather than their back, which will prevent injury.
A nurse on a medical-surgical unit is caring for a client transferred from another department...
Receiving moderate sedation The nurse should verify that the client has given informed consent prior to receiving moderate sedation because this involves anesthesia.
A nurse walks into the nurses' station and sees several staff members looking at the EMR of a celebrity on another unit...
Remind the staff members that this is a breach of confidentiality When using the urgent vs nonurgent approach to client care, the nurse determines that the first action is to intervene immediately to prevent any further breach in confidentiality.
A nurse asks a newly hired assistive personnel to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure that the AP is qualified to perform the task?
Review the AP's skill competency checklist A review of the AP's checklist should validate that they have demonstrated the ability to safely perform the procedure
A nurse is caring for a pt who is comatose...
Review the client's request with the family
A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit...
Role model a positive approach to the changes Encourage staff members who support the changes to discuss the issue with resistant staff
A nurse on a medical-surgical unit has arrived late to work multiple times over the past several weeks...
Schedule a meeting with the nurse Provide written reprimand Temporarily remove the nurse from the scheduled shifts Terminate the nurse's employment
A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert PICC...
State Nurse Practice Act (NPA) The nurse should consult the NPA in this situation because the NPA defines the scope and boundaries of professional nursing practice. The NPA provides guidelines for developing standardized procedures within specific facilities where expanded nursing functions have been approved in collaboration with nurses, providers, and administration.
The American Academy of Nursing
The AAN is a professional organization that generates, synthesizes, and disseminates nursing knowledge to contribute to health policy and practice for the benefit of the public and the nursing profession in general.
The Agency for Healthcare Research and Quality
The AHRQ is part of the United States Department of Health and Human Services, which supports research and is designed to improve the outcomes and quality of health care.
National League for Nursing
The NLN is a national organization for faculty nurses and leaders in nurse education. It offers faculty development, networking opportunities, testing services, nursing research grants, and public policy initiatives.
A nurse is developing a plan of care for a school-aged child whose family is homeless...
The child has red fissures at the corners of the mouth Using Maslow's hierarchy of needs, the nurse should determine that the priority finding is red fissures at the corners of the child's mouth. This can indicate a vitamin B deficiency, which is a physiological need.
A case manager is planning an interprofessional conference for a client who is 3 days post following an open reduction and internal fixation of the right hip...
The client refuses to attend physical therapy sessions The greatest risk to this client is postoperative complications due to immobility, such as atelectasis or pneumonia; therefore, the priority for discussion is the client's refusal to participate in physical therapy.
A nurse is caring for a client who is 3 days post following open heart surgery...
The client's level of consciousness The nurse should include objective data regarding the client's current consciousness status in the verbal report.
A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of following information can assist the nurse in evaluating the cost effectiveness of the care?
The length of the client's stay. The client's clinical pathway is a standardized approach to assist the nurse to provide cost-effective client care and shorten the length of stay.
A charge nurse is observing a nurse perform a sterile dressing change for a client...
The nurse places the surface package with the top flap opening away from the body The nurse should place the sterile package on a flat surface so that the top flap opens away from the body. This prevents the contents of the sterile package from becoming contaminated. The nurse should pinch the flap on the outside of the package first to open it. The nurse should open the left flap of the package with the left hand. This prevents the nurse from reaching over the package and contaminating the contents of the package. The nurse should pull the last flap of the package toward the body by pulling the corner down. This prevents the contents of the package from becoming contaminated.
A nurse is conducting an orientation class for new clients and their families at a long-term facility...
The right to be treated with respect and dignity The right to refuse their medication The right to leave regardless of provider recommendations The right to be fully informed of their health conditions
Justice is an ethical principle in which the nurse's actions are taken to seek fairness, where all clients are treated equally regardless of sex, sexual orientation, religion, ethnicity, disease, or social standing. Beneficence is an ethical principle in which the nurse's actions are taken to "do good" and promote goodness and kindness.
Utility is an ethical principle in which the nurse's actions are taken to bring the most to the greatest number of people, where the good of many will outweigh the needs of an individual client.
aA charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary TB...
Wear an N95 respirator mask when in the client's room The nurse should wear an N95 respirator mask when caring for clients who have suspected pulmonary tuberculosis.
Digoxin
value is within the expected reference range of 0.8 to 2 ng/mL
WBC count
value is within the expected reference range of 5,000 to 10,000/mm3