Management of Care (#3)

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? You Selected: Discuss the unit's policy with the charge nurse. Correct response: Discuss the unit's policy with the charge nurse. Explanation: Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonate's parents are married or if the mother is an emancipated minor. Therefore, the adolescent mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the neonate does have a say in visitors seeing her baby. Because the family dynamics aren't clear in this scenario, the best answer would be to check with the charge nurse who knows the unit's policy. Although the neonate's father may have demanded to see the baby, the question doesn't indicate violent or threatening behavior; therefore, notifying security isn't necessary. The nurse can instruct the father's parents on how to gown and glove before visiting the neonate if they have permission to visit. Because the family dynamics aren't known, inviting everyone to gather in a conference room isn't advisable. Add a Note Question 2 See full question 46s The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give hand-off of care reports at which times? Select all that apply. You Selected: when the nurse goes to lunch change of shift change of nurses Correct response: change of shift change of nurses when the nurse goes to lunch Explanation: Effective communication is essential when managing client safety and preventing errors. "Hand-off reports" should be made at shift change, when there is a change of nurses or when the nurse leaves the unit, and when the client is discharged or transfers to another unit. There does not need to be a handoff report when the unit clerk leaves the unit or when new medication prescriptions are written. Add a Note Question 3 See full question 42s When preparing for a spiritual counselor to visit a hospitalized patient, the nurse should: You Selected: Take measures to ensure privacy during the counselor's visit. Correct response: Take measures to ensure privacy during the counselor's visit. Explanation: Visits between a patient and a spiritual counselor require privacy. The details of the meeting are not typically documented in the patient's chart, though the fact that the visit took place is often noted. The nurse may be present during the meeting, but this should take place at the patient's request. Spiritual counselors do not require administrative approval; patients and their families are normally able to seek spiritual help from whomever they prefer. Add a Note Question 4 See full question 1m 28s Which procedures can the nurse working on a pediatric floor safely delegate to the licensed practical/vocational nurse (LPN/VN)? Select all that apply. You Selected: inserting hearing aids administering gastrostomy tube feedings Correct response: administering gastrostomy tube feedings inserting hearing aids Explanation: In general, LPN/VNs may perform skills related to feeding, oral medication administration, and activities of daily living, such as insertion of a hearing aid. Refilling a baclofen pump constitutes administering an intrathecal medication and is beyond the scope of practice for LPN/VNs in most areas. Some institutions allow LPN/VNs to give IV push medicines; however, special training is required. Communicating with the health care provider (HCP) would require discussion of the client's assessments and evaluations, which fall under the RN scope of practice. Add a Note Question 5 See full question 1m 45s A client tells the visiting community health nurse that another client's name and phone number were seen on the call display after the previous day's nurse used the client's home phone. What should the nurse do in response to this conversation? You Selected: Discuss the matter with the other nurse, reminding him/her not to use the client's phone because it has a call display feature. Correct response: Discuss the matter with the other nurse, reminding him/her not to use the client's phone because it has a call display feature. Explanation: Leaving personal information in view of other people is a breach of confidentiality. The nurse should approach the other nurse and inform him/her of the incident. The other options are incorrect because they do not protect the client's privacy and do not address the behavior of the other nurse. In which circumstance may the nurse legally and ethically disclose confidential information about a client? You Selected: A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency Correct response: A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency Explanation: A nurse may lawfully disclose confidential information about a client when the welfare of a person or group of people is at stake. A health care provider must inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder; disclosing the condition is in the best interest of public safety and the client's well-being. Confidentiality of HIV testing is required, but the client, who's HIV positive, should be encouraged to share the information with his family. Many state legislatures require maintaining confidentiality of HIV testing. The nurse may not disclose a diagnosis of pancreatic cancer or a pregnancy because these situations don't affect the welfare of a group of people. Add a Note Question 2 See full question 22s A nurse manager of the pediatric unit discovers that she is overbudget on supplies. How could each nurse assigned to the unit help with cost containment? You Selected: Use care pathways to specify care and identify daily outcomes. Correct response: Use care pathways to specify care and identify daily outcomes. Explanation: Using care pathways to specify care and identify daily outcomes ensures that clients progress toward a timely discharge and that resources are used appropriately. A longer hospital stay requires more resources, which, in turn, leads to a more costly health care bill. Generic brands are less expensive than brand-name products; therefore, the use of generics should be encouraged. Filling a personal medicine cabinet with supplies from work constitutes stealing. Ordering supplies that are soon to be expired could be contributing to running over budget. Add a Note Question 3 See full question 37s A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first? You Selected: Initiate fetal and contraction monitoring. Correct response: Initiate fetal and contraction monitoring. Explanation: The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other orders. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if ordered. Add a Note Question 4 See full question 48s The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? All options must be used. You Selected: a client with peptic ulcer disease experiencing a sudden onset of acute stomach pain a client who is requesting pain medication 2 days after surgery to repair a fractured jaw a client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests a client awaiting surgery for a hiatal hernia repair at 1100 Correct response: a client with peptic ulcer disease experiencing a sudden onset of acute stomach pain a client who is requesting pain medication 2 days after surgery to repair a fractured jaw a client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests a client awaiting surgery for a hiatal hernia repair at 1100 Explanation: The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention. It is also important for the nurse to thoroughly assess the nature of the client's pain. The client with the fractured jaw is experiencing pain and should be assessed next. The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. Last, the nurse can assess the client before surgery. Add a Note Question 5 See full question 48s A client who has been recently extubated has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP? You Selected: hemoglobin and hematocrit Correct response: hemoglobin and hematocrit Explanation: The nurse should review the CBC with differential to evaluate the client's hemoglobin and hematocrit, which are abnormal and should be reported to the HCP. Anemia leads to decreased oxygen-carrying capacity of the blood. A client unable to compensate for the anemia may experience a profound sense of dyspnea. There has been a significant drop in the hemoglobin and hematocrit since the previous report, and these should be reported to the HCP. The monocytes are within normal range. HA1c is a laboratory test evaluating glycosylated hemoglobin and is in the normal range. This test is used to diagnose diabetes and/or monitor diabetic glucose control over time. PT is a coagulation study reflecting liver function and clotting time and is in the normal range. Which task may be safely delegated to a licensed practical nurse (LPN)? You Selected: Changing the dressing of a client who underwent surgery 2 days ago Correct response: Changing the dressing of a client who underwent surgery 2 days ago Explanation: The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the postanesthesia care unit is beyond the scope of practice for an LPN; LPNs aren't permitted to give I.V. push drugs. Add a Note Question 2 See full question 1m 44s A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? You Selected: The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. Correct response: The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. Explanation: In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which indicates a comatose state. The client cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client's fiancée cannot sign the consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The HCP should insert the catheter in this emergency. He does not need to get a consultation from another HCP. When consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client's next of kin. Add a Note Question 3 See full question 55s A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do? You Selected: Obtain a trained medical interpreter. Correct response: Obtain a trained medical interpreter. Explanation: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the client's confidentiality. Using the UAP or limited Spanish and nonverbal communication do not ensure accuracy of interpretation and back-translation into English. Add a Note Question 4 See full question 37s The nurse is caring for an 8-year-old with a life-threatening illness. The parents do not speak the native language and want the child discharged so they can pursue alternative therapies that they believe will be less expensive. What is the most important action taken by the nurse to help the family and the child? You Selected: Arrange to have a translator present when talking with the parents. Correct response: Arrange to have a translator present when talking with the parents. Explanation: A translator is an immediate priority. No effective health teaching or social intervention will be effective until there is an established means of communication with the family. Add a Note Question 5 See full question 1m 1s A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply. You Selected: adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours older adult client who had hip replacement surgery and needs to walk in the hall with a walker Correct response: older adult client who had hip replacement surgery and needs to walk in the hall with a walker adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours Explanation: The UAP can assist clients ambulate and take vital signs. It is within the RN scope of practice to teach the client to administer insulin, change dressings, and administer tube feedings.

LvL 0 to 1

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? You Selected: Acute pain Correct response: Acute pain Explanation: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time. Add a Note Question 2 See full question 1m 18s The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply. You Selected: Client ambulated to end of hallway. Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Correct response: Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway. Explanation: Client vital signs, observation of a dressing, and documentation of the activity of a patient represent objective data. Using words such as "seems" or "appears" implies subjectivity on the part of the nurse. Add a Note Question 3 See full question 1m 11s A pregnant client is seeking information from the nurse about a home birth with registered midwives. Which of the following statements lets the nurse know that the client has considered the risks and benefits of using a midwife? Select all that apply. You Selected: "I will develop a list of questions to use in interviewing potential midwives." "I understand the complications that could occur in a home birth setting." "I realize that I may need to be transferred to a hospital if complications develop." Correct response: "I will develop a list of questions to use in interviewing potential midwives." "I understand the complications that could occur in a home birth setting." "I realize that I may need to be transferred to a hospital if complications develop." Explanation: Developing a list of questions, understanding the complications that could occur with a home birth, and realizing that a transfer to a hospital might be necessary all demonstrate that the client has researched a home birth and is aware of the positive and negative factors that could occur. These choices show that the client is approaching the situation in a realistic and educated manner. Looking for an obstetrician and stating that a home birth is safer with a physician are not appropriate answers. Add a Note Question 4 See full question 20s A nurse in a long-term care facility consistently administers clients' medications 60 to 90 minutes after the scheduled administration time. The nurse also leaves scheduled treatment procedures for nurses to complete on the next shift. Which of the following would be an appropriate strategy for this nurse to pursue? You Selected: Seek input and direction on time management and priority setting. Correct response: Seek input and direction on time management and priority setting. Explanation: The nurse should recognize the limitations of his/her own competence and seek assistance when necessary. The nurse should also organize his/her workload effectively, which includes time management and delegation. The other options do not address strategies to improve the nurses' organization or time management. Add a Note Question 5 See full question 18s The parents of a healthy infant request information about advance directives. The nurse's best response is to You Selected: ask open-ended questions to understand the parents' concerns. Correct response: ask open-ended questions to understand the parents' concerns. Explanation: Asking open-ended questions about the parents' concerns will help the nurse understand why they are asking for information. Advance directives are rarely prepared for healthy infants. The parents' request for information may indicate distress, and the nurse should obtain more details before giving them information. It is not necessary for the parents to discuss this with a lawyer as the infant is healthy. Providing the parents with a brochure about advance directives would help the parents understand what they are, but the nurse must obtain additional information.

LvL 2 to 3

A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? You Selected: "By discharge, the client correctly identifies three potassium-rich food sources." Correct response: "By discharge, the client correctly identifies three potassium-rich food sources." Explanation: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior. She should express that behavior in terms of client expectations and should indicate a time frame in which to accomplish it. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable outcomes. Understanding all complications of a disease process isn't measurable or specific to the nursing diagnosis listed. Add a Note Question 2 See full question 26s A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? You Selected: Administer an opioid analgesic as prescribed. Correct response: Administer an opioid analgesic as prescribed. Explanation: If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention. Withholding fluids will make urine more concentrated and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does not take priority over pain management. Add a Note Question 3 See full question 1m 8s The nurse transfers a child who has had open heart surgery from the intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. What information should the nurse include in the handoff report? Select all that apply. You Selected: current vital signs time of the most recent dose of pain medication medications being used potential for blood pressure to drop drip rate for the intravenous infusion Correct response: medications being used current vital signs potential for blood pressure to drop drip rate for the intravenous infusion time of the most recent dose of pain medication Explanation: The report made when nurses are "handing off" a client from one nursing unit to another must include information about the condition of the client, potential for changes in the client's condition, current medications, and care and services received. It is not necessary to know what medications were given in surgery to provide safe care at this point. Add a Note Question 4 See full question 1m 9s A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message: "You are not authorized to view this information." What is the reason for this message? You Selected: The laboratory assistant can retrieve medical records but cannot view the details. Correct response: The laboratory assistant can retrieve medical records but cannot view the details. Explanation: It is important to block the type of information that personnel in various departments can retrieve. Laboratory assistants can retrieve information from the medical records, but they cannot view information in the client's personal history. Even if the laboratory assistant had the correct access number and the password or was trying to view archived data, he or she would not have been able to access a client's personal history. Add a Note Question 5 See full question 15s A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP? You Selected: "Your behavior in this situation is considered verbal abuse." Correct response: "Your behavior in this situation is considered verbal abuse." Explanation: Reprimanding a client for something that is beyond the client's control is considered abusive. The other options do not help the UCP understand the abusive behavior.

LvL 3 to 4

A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process? You Selected: "I will have the transplant coordinator speak with you to answer your questions." Correct response: "I will have the transplant coordinator speak with you to answer your questions." Explanation: The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers. Add a Note Question 2 See full question 42s The nurse develops the plan of care for a child with early Duchenne's muscular dystrophy. What is the priority goal for this client? You Selected: Maintain function of unaffected muscles. Correct response: Maintain function of unaffected muscles. Explanation: The primary nursing goal is to maintain function in unaffected muscles for as long as possible. There is no effective treatment for childhood muscular dystrophy. Children who remain active are able to forestall being confined in wheelchair. Remaining active also minimizes the risk for social isolation. Preventing rather than encouraging wheelchair use by maintaining function for as long as possible is an appropriate nursing goal. Children with muscular dystrophy become socially isolated as their condition deteriorates and they can no longer keep up with friends. Maintaining function helps prevent social isolation. Circulatory impairment is not associated with muscular dystrophy. Add a Note Question 3 See full question 24s A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)? You Selected: Epoetin alfa 6500 U SQ daily. Correct response: Epoetin alfa 6500 U SQ daily. Explanation: The order written as "Epoetin alfa 6500 U SQ daily" is incorrect according to the Joint Commission's "do not use" list. "U" should not be used because it may be mistaken as zero (0), 4 (four), or cc. The healthcare professional should write "unit" instead. The other medication orders are written correctly. The order for diazepam does not include a trailing zero in the dosage. The order for levothyroxine sodium includes a leading zero prior to the dose. The acetaminophen order is correct in the use of the word "every" instead of Q.D., QD, q.d., or qd. Add a Note Question 4 See full question 29s A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? You Selected: Protects the client's right to self-determination in health care decision making. Correct response: Protects the client's right to self-determination in health care decision making. Explanation: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will. Add a Note Question 5 See full question 18s A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? You Selected: Discuss the breach of practice with the physician. Correct response: Discuss the breach of practice with the physician. Explanation: The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step.

LvL 4 to 5

A nurse is using the computer when a client calls for pain medication. Which action by the nurse helps maintain computer security? You Selected: Logging out of the computer, then administering the pain medication Correct response: Logging out of the computer, then administering the pain medication Explanation: A nurse should meet a client's request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice. Add a Note Question 2 See full question 30s A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? You Selected: Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Correct response: Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Explanation: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record. Add a Note Question 3 See full question 21s The primigravid client is at +1 station and 9 cm dilated. Based on these data, what should the nurse do first? You Selected: Encourage the client to breathe through the urge to push. Correct response: Encourage the client to breathe through the urge to push. Explanation: The urge to push is often present when the fetus reaches + stations. This client does not have a cervix that is completely dilated and pushing in this situation may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated. Comfort measures are important for the client at this time but are not the highest priority for the nurse. Add a Note Question 4 See full question 36s A 15-year-old primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? You Selected: "I'll bring the baby to you for feeding." Correct response: "I'll bring the baby to you for feeding." Explanation: After birth, the client should make the decision about how much she would like to participate in the neonate's care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The health care provider (HCP) does not need to be contacted about the client's desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby. Add a Note Question 5 See full question 27s A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem? You Selected: Speak to the coworker when she returns to the unit. Correct response: Speak to the coworker when she returns to the unit. Explanation: When a nurse discovers substandard practice by another nurse, it is always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse supervisor first does not promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issue can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

LvL 5 to 6

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider? You Selected: IV rate increase Correct response: IV rate increase Explanation: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, normal saline, or albumin. Add a Note Question 2 See full question 23s A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to: You Selected: reassign the client to another nurse who is experienced in blood administration. Correct response: reassign the client to another nurse who is experienced in blood administration. Explanation: The best option in this situation is to reassign the client to a nurse with experience in blood administration. The policy book and explanation are resources, but the nurse is a pediatric nurse who has never administered blood before, and therefore, an unsafe situation is created. An explanation is insufficient teaching for safe and proper blood administration, and reading policy book may be a resource, but having an experienced nurse administer the blood is a safer decision. Asking about the nurse's confidence is not sufficient evidence that the nurse can administer the blood. Asking an experienced nurse to administer the blood is a safer option. Add a Note Question 3 See full question 1m 8s After receiving a change-of-shift report at 0700, the nurse should assess which client first? You Selected: a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain Correct response: a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain Explanation: Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should been seen first by the nurse. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The client should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon, but do not have needs as urgent as this client. Add a Note Question 4 See full question 18s A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take? You Selected: Note that the nurse caring for the client cannot be a witness. Correct response: Note that the nurse caring for the client cannot be a witness. Explanation: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining. Calling for a physician or asking another colleague to sign is an inappropriate action. Add a Note Question 5 See full question 19s When taking a client's vital signs on the first postoperative day, the unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature is 100° F (37.8° C). After encouraging the client to use the incentive spirometer, the nurse should delegate which activity to the UAP? You Selected: Place a hyperthermia blanket on the client's bed. Correct response: Place a hyperthermia blanket on the client's bed. Explanation: Temperature variation in the postoperative period provides valuable information about a client's status. Fever may occur at any time during the postoperative period. A mild elevation (up to 100.4° F [38° C]) during the first 48 hours usually reflects the surgical stress response. After the first 48 hours, a moderate to marked elevation (higher than 99.9° F [37° C]) is usually caused by infection. It is not appropriate to do any of the other options to lower a client's temperature at this time. A severe winter storm has prevented most staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. A nurse-manager must decide which nursing care delivery system (model) (NCDS) should be implemented for the best possible client care during this staffing crisis. The nurse-manager directs the staff to implement which NCDS (NCDM)? You Selected: Functional nursing Correct response: Functional nursing Explanation: Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system (model) requires the fewest staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited number of staff who must care for a large number of clients. Primary nursing and case management require more registered nurses than are currently available. Add a Note Question 2 See full question 15s After the physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond? You Selected: Provide the information requested. Correct response: Provide the information requested. Explanation: As part of the multidisciplinary team, the nurse is empowered to assist the client to better understand the process, as long as the nurse has an understanding of the treatment plan. The nurse shouldn't discourage the client from participating in the research study. Providing information to the client about the clinical trial isn't beyond the scope of nursing practice. The information doesn't need to come from the physician who originally presented the material to the client. Add a Note Question 3 See full question 1m 16s The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do? You Selected: Assess the client to determine why she wants to sit up. Correct response: Assess the client to determine why she wants to sit up. Explanation: The nurse should first determine why the client wants to sit up and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising the side rails and elevating the head of the bed do not address the client's needs. Add a Note Question 4 See full question 29s A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do? You Selected: Find another nurse to cover the unit and send the nurse back to the surgery unit. Correct response: Find another nurse to cover the unit and send the nurse back to the surgery unit. Explanation: Nurses are accountable for their practice and must recognize the limitations of their own competency. To the extent possible, the nurse manager must ensure nurses working on their units have the required knowledge, skills, and competencies. The other options are incorrect because they do not ensure that the clients are receiving care from the most competent nurse. Add a Note Question 5 See full question 38s A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client's scalp. Which referral should the nurse make first? You Selected: a health care provider Correct response: a health care provider Explanation: The client is exhibiting signs of hypothyroidism, which includes hair loss, pain, fatigue, and increased sensitivity to cold. Hypothyroidism may be impacting the client's mood, ability to concentrate, physical sensations, and energy levels. Resolving potential biological causes of her symptoms takes priority over rehabilitation strategies or psychological approaches.

LvL 6 to 7

A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift? You Selected: Bottle- or breastfeeding preference. Correct response: Bottle- or breastfeeding preference. Explanation: The bottle- or breastfeeding preference is the least important information to be reported to the oncoming shift. The bottle- or breastfeeding plans will be important after delivery as many mothers breastfeed within an hour after delivery. The client's obstetrical history is a higher priority because it provides information about previous birthing experience. Information on cervical effacement, dilation, and station indicates the current state of labor and is essential for planning continuity of care for this client. Nurses on the incoming shift should also know the extent of support the client will need and who is currently providing that support. Add a Note Question 2 See full question 26s The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription? Correct response: an x-ray for gastric tube placement Explanation: The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when a gastric tube cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a TEF. Add a Note Question 3 See full question 55s The nurse transfers a child who has had open heart surgery from the intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. What information should the nurse include in the handoff report? Select all that apply. You Selected: medications being used current vital signs drip rate for the intravenous infusion potential for blood pressure to drop time of the most recent dose of pain medication Correct response: medications being used current vital signs potential for blood pressure to drop drip rate for the intravenous infusion time of the most recent dose of pain medication Explanation: The report made when nurses are "handing off" a client from one nursing unit to another must include information about the condition of the client, potential for changes in the client's condition, current medications, and care and services received. It is not necessary to know what medications were given in surgery to provide safe care at this point. Add a Note Question 4 See full question 23s What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day? You Selected: Complete regular admission procedures. Correct response: Complete regular admission procedures. Explanation: Clients entering the hospital setting for outpatient surgery have regular admission procedures conducted by the nurse. Scheduling of screening tests and initial teaching is completed in the days prior to the surgery. Same-day surgery and discharge may require community-based follow-up, but it generally does not require long-term care. Detailed information on the procedure will be provided by the physician performing the procedure. Add a Note Question 5 See full question 32s The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client is anxious because he fears he will not be monitored as closely as he was in the CCU. How can the nurse allay his fears? You Selected: Assign the same nurse to the client when possible. Correct response: Assign the same nurse to the client when possible. Explanation: Assigning the same nurse to the client when possible provides continuity of care and stability, thereby reducing his anxiety. An anxiolytic might be counter-productive and "overkill," he needs reassurance first. The client might have been the "most stable" choice in the event of an urgent need for a CCU bed. A room close to nurses' station would provide this client with a sense of security because the nurses are close by in the event of an emergency.

LvL 7 to 8