module 5

A case manager is reviewing progress notes in a client's medical record. Which notation indicates the need for follow-up?

2

A nurse who recently learned she is pregnant has just received client assignments for the day. Which client assignment should the nurse question as being inappropriate?

A client with a solid sealed cervical radiation implant

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately take which action?

Ask the nurse manager of the intensive care unit to discuss the assignment.

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first?

Ask the nurse whether she intends to report the error

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action?

Check the placement of the tube

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which options are accurate descriptions of these standards of care? Select all that apply.

Define professional practice Correct Have some similarity to policies and procedures Are authoritative statements that describe a common or acceptable level of client care or performance

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?

Keeping the door to the client's room closed

A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?

Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures

An nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?

Peripheral pulses

Which situation is an example of the use of evidence-based practice in the delivery of client care?

Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action?

administer cpr

A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

Realigning the client

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first?

Respiratory status

The nurse is working with a newly employed nurse in the clinic. A nursing staff member approaches the nurse and announces that the newly employed nurse is not using alcohol swabs to clean skin before administering intramuscular medications. What is the appropriate way for the nurse to handle this situation?

Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse provides the client with which information?

She will need to sign an informed consent form

A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up?

a cleint exhibits signs of increased icp after a craniotomy

A nurse working the 7 a.m. to 3 p.m. shift is reviewing the records of the assigned clients. Which client should the nurse assess first?

a cleint scheduled for hemodialysiss at 10 am

A nurse has received the assignment for the day shift. Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared to first?

a client who is scheduled for surgery at 1 pm

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up? Select all that apply.

a client with central venous catheter has a temp of 100.6

A nurse is assigned to care for four clients. Which client should the nurse assess first?

a client with tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?

administers the injection 2 inches below the acromion process

A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

ask the client for permission to lock the necklace in the hospital safe

A nurse preparing a client to go to the radiology department for a neck x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take?

assisting the client in pinning the medal chain to the waistband of the clients pj bottoms

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?

ot

The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

providing oral care to an uncounsious client who requires oral care

A nurse is supervising a nursing assistant ambulating a client with right-sided weakness. The nurse would conclude that the nursing assistant is performing the procedure incorrectly after observing the nursing assistant taking which action?

stands behind the client

A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement is written for which purpose?

to outline what the organization plans to accomplish

A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

its called furosemide and it will promote urination and rid your body of the excess fluid it can cause an alteration in electrolyte levels so well need to increase the potassium in your diet

The nurse notes that a health care provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?

Contacting the health care provider

A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the health care provider, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?

Discussing the situation with the nurse manager

A nurse discusses staff empowerment with the nursing team. The nurse explains that staff empowerment has which function?

Fosters the growth of others so that they are less dependent on the leader

A nurse in a long-term care center notes that an employee is constantly calling in sick. Which action should the nurse take initially to handle this problem?

Reminding the employee of the employment standards of the agency

A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the health care team does the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?

Social worker

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first?

Submerge the end of the chest tube in a bottle of sterile water.

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?

The client's intake was 360 mL

A nurse, newly employed by a home health agency, is told that the organization's decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in whom?

a few individuals such as the board of directors

A client with leukemia is being considered for a bone marrow transplant. The health care team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of health care ethics is the team practicing?

nonmaleficence

A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)?

recording the urinary output for a client with renal calculi whose urine must be strained

A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?

report the incident to the nursing supervisor

The nurse reviewing a client's record for the 7 a.m. to 7 p.m. work shift sees that the following medications are prescribed. Which medication should the nurse plan to administer first?

4

A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is "uncooperative and a real pain to care for." The nurse would most appropriately manage this issue by taking which action?

Discouraging the judgmental comments

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first?

Contacting the health care provider

In which situation is the nurse upholding the ethical principle of fidelity?

Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

Contacting the surgeon and requesting that she visit the client to answer her questions

A client receives cefazolin sodium (Ancef) via the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the health care provider, and begins to document the reaction in an incident report. The nurse most accurately documents with which statement?

During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified

A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?

Expert powe

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?

I have plans after work and will not be able to work overtime.

A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

Oxygenating the client with 100% oxygen

A licensed practical nurse arrives at work at the long-term care center and is immediately faced with several activities that require attention. Which activity will the nurse attend to first?

Task assignments for the day

A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act for which purpose?

To be aware of the role of the licensed nurse

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart for which reason?

To be familiar with the organization's line of authority

A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate constitutes a negligent act?

Using clean gloves to change a gastrostomy tube dressing

A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?

assisting a cleint with dysphagia in eating

A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant?

assisting a client who needs frequent ambulation with a walker

A nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse?

calling the hcp who gave the telephone prescription to clarify the prescription

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by undertaking which action?

calling the surgeon and asking that the risks be explained to the client

A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

check the clients loc and vital signs

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if the new graduate takes which action?

documents task completions and client infor at the end of the day

Which action exemplifies the use of evidence-based practice in the delivery of client care?

donning sterile gloves to change an abdominal wound dressing

A nurse has assigned several nursing tasks to staff members. Which is the nurse's primary responsibility after assigning tasks?

following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task

A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which services does the nurse suggest a referral?

home care

A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN?

monitoring a client receiving oxygen who frequent pulse oximentry monitoring and respiratory treatments

nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the health care provider. The health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first?

inform the hcp that removal of a chest tube is not a nursing procedure

A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?

meeting with the cna and encouraging him to express his feeling regarding the change

A licensed practical nurse tells the certified nursing assistant (CNA) staff that they will need to comply with the mandatory overtime policy that the long-term care facility has implemented. Later that day, the nurse overhears a CNA complaining about the policy and telling other CNAs that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse to use in dealing with the conflict?

meeting with the cna regarding her behavior regarding the overtime policy

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?

obtaining the assigned medical record from the hospitals medical record room to review documentation made during a clients hospital stay

A nurse is planning the assignments for the shift. Which task should the nurse assign to the nursing assistant?

performing hygiene for a cleint with diarrhea on whom contact precautions have been imposed

A nurse planning care for her assigned clients understands that which aspect is the purpose of the hospital's standards of care?

provide direction for the practice of nursing

A licensed practical nurse (LPN) is planning task assignments for five clients on the skilled nursing unit in a long-term care facility. The team includes another licensed practical nurse (LPN) and a nursing assistant. Which tasks should the nurse assign to the LPN? Select all that apply.

providing teaching for a client with colostomy who requires reinforcement regarding the procedure for irrigation administering regular insulin in accordance with a sliding dosage scale every 4 hours to a client with diabetes

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

she will have to discuss the prescribed test with the client

The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right?

telling the client that he or she may not leave the hospital

A licensed practical nurse (LPN) is planning client assignments for the day. Which tasks should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply.

transporting a client to the radiology deparrtment in a wheel chair recording the urine output for a client with foley catheter for whom a 24 hour urine collection is in progress

A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he has gonorrhea." How should the nurse respond to the secretary?

we cant discuss a clients medical condition

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply.

you are responsible for your own actions it carries legal implications for task performance you msut answer for the care that you ask others to complete it refers to the process of answering or being responsible for what occurs

A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should take which action?

explain to the client why the wedding band must be removed

A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the most appropriate nursing action in this situation?

asking the hcp to write the prescription in the clients record before leaving the nursing unit

A nurse is working in an urgent care center during the night shift. A client arrives at the center for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client's injury, the nurse should take which action?

checkt he unit policy for the protocol for the care of cleints who ahve been sexually assaulted

A nurse is providing a change-of-shift report on the assigned clients using an audiotape. Which pieces of information should the nurse include in the report about each assigned client? Select all that apply.

client needs and priorities of care current diagnosis and any secondary diagnoses results of lab studies conducted that day client response to treatments implemented that day

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, which is the first activity that the nurse would suggest to the task force?

conducting a community survey to assess community perceptions regarding school violence

nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply.

conducting client rounds before taking the break taking the break in the staff lounge located on the nursing unit

A nurse at the long-term care unit on the 11 p.m. to 7 a.m. shift is gathering the nursing staff together to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which action is most appropriate for the nurse to take?

contact the nursing supervisor

A health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take?

contacting the nursing supervisor

The nurse is working with the registered nurse who has accepted a new position as case manager in a hospital. The nurse realizes which responsibilities are part of the registered nurse's new role? Select all that apply.

evaluating and updating the plan of care as needed assessing the clients needs for home supplies and equipment coordinating consulations and referrals to favilitate discharge establishing a safe and cost effective plan of care with the client

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should take which action?

explain to the tv crew that videotaping is not allowed

A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond?

telling the hcp that slow codes are not acceptable

A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, "I don't want a bath. I've been up all night, and I'm clean enough." The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?

telling the nursing student to allow the client to rest

A man who is visiting his wife in a long-term care facility for people with Alzheimer disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital health care provider that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember?

that a dnr order may be written by a clients hcp

A client asks a nurse about the procedure for becoming an organ donor. The nurse provides the client with which information?

that natomic gifts must be made in writing signed by the client

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?

the care map outlines the day to day expected outcomesof care and the outcomes anticipated at discharge

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands which information about DNR orders?

the dnr order requires frequent review as specified by state or agency policy

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should provide the client with which information?

the dnr request should be discussed with the hcp who will write the order

A nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes?

the hcp was called to clarify the prescription for morphine sulfate

The registered nurse (RN) has made client assignments for the licensed practical nurse (LPN). Which assignment should the LPN question as being beyond the scope of the LPN?

the lpn is assigned to care for woman with newly diagnosed leukemiawho will be receiving her initial dose of chemo

Which action by the nurse represents the ethical principle of beneficence?

the nurse administers an immunization to a child even though it may cause discomfort

A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, "The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection." Which statement accurately describes the nurse's response to the client?

the nurse could be charged with assault

An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client's parents but is unsuccessful. What action is necessary with regard to informed consent for the surgery?

the nurse understands that consent is not needed

A nurse is employed in a community hospital as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?

the official power to see that n organizational decision is enforced