RN Leadership Online Practice 2023B

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? a. Assist in weighing the options involved in the decision. b. Provide a legal representative for the family. c. Recommend the best course of action for the client. d. Decide how the nursing team should resolve the dilemma.

a. 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 walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first? a. Remind the staff members that this is a breach of confidentiality. b. Discuss the issue with the nurse manager. c. Request that an administrative restriction be placed on the client's record access. d. Prepare a memo for the facility ethics committee

a. Remind the staff members that this is a breach of confidentiality. When using the urgent vs nonurgent approach to client care, the nurse should intervene immediately to prevent any further breach in confidentiality. Therefore, this action should be the nurse's priority.

A nurse is caring for a 19-year-old client who has just been informed that their cancer has metastasized. The client tells the nurse that they do not want to continue chemotherapy. Which of the following responses should the nurse make? a. "I will have the provider discuss treatment options with your parents." b. "I will gather information about palliative care for you." c. "I will contact your spiritual advisor to discuss this decision with you." d. "I will contact your parents about becoming your designees in your durable power of attorney."

b. "I will gather information about palliative care for you." The nurse is acknowledging the client's right to refuse treatment and is demonstrating support by offering to discuss end-of-life care options.

A nurse is caring for a client who recently learned they have a mutation of the BRCA2 gene. The client states that they do not plan to tell their adult children about the diagnosis. Which of the following responses displays client advocacy by the nurse? a. "You should tell your children because this could affect their health as well." b. "Let's review what you understand about this test result." c. "Why would you not want to share this information with your children?" d. "I feel it would be best for you to reconsider your decision."

b. "Let's review what you understand about this test result." The nurse should use therapeutic communication techniques to encourage the client to share their point of view, and to convey respect for the client's decisions. By seeking to understand the client's perceptions in a nonjudgmental manner, the nurse is displaying client advocacy.

A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make? a. "Procedures prescribed by the provider do not require consent." b. "This is a procedure that does not require written informed consent." c. "You are right. I will discuss this issue with the charge nurse." d. "Would you mind signing the informed consent form for the procedure at this time?"

b. "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 receiving a change-of-shift report. Which of the following clients should the nurse assess first? a. A client who has a WBC count of 15,000/mm3 and is receiving antibiotics. b. A client who had abdominal surgery 6 hr ago and has had a heart rate of 120/min for the last 2 hr. c. A client who is requesting pain medication 24 hr after an open reduction and internal fixation (ORIF) of the left ankle. d. A client who has pneumonia, an oxygen saturation of 95%, and is refusing prescribed medication.

b. A client who had abdominal surgery 6 hr ago and has had a heart rate of 120/min for the last 2 hr. A client who had a heart rate above the expected reference range of 60 to 100/min for the last 2 hr is unstable due to the risk of hypovolemia caused by hemorrhage. Therefore, this client is the nurse's priority.

A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse? a. A client who has heart failure and 2+ edema of the lower extremities. b. A client who is 2 days postoperative and has a urine output of 20 mL/hr. c. A client who started taking verapamil and has a heart rate of 75/min. d. A client who is receiving morphine and reports nausea.

b. A client who is 2 days postoperative and has a urine output of 20 mL/hr. When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a urine output of 20 mL/hr, which is below the expected reference range and might indicate that the client is hypovolemic or experiencing renal failure complications.

An occupational health nurse is triaging clients at the site of an industrial explosion. A class Ill, or green tag, should be assigned to the client with which of the following findings? a. Open femur fracture b. Facial contusions c. Hypovolemic shock d. Penetrating spinal injury

b. Facial contusions The nurse should assign a class Ill, or green tag, to a client who has facial contusions.

A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behaviors should the charge nurse identify as an indication that the staff nurse might be working while impaired? a. Spends free time conversing with other staff at the nurses' station. b. Frequent use of the restroom c. Asks other nurses to administer pain medication for their clients d. Delegates tasks to assistive personnel (AP)

b. Frequent use of the 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 nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task? a. Show the AP how to remove an indwelling urinary catheter. b. Review the AP's skill competency checklist. c. Ask the AP if they know how to remove an indwelling urinary catheter. d. Pair the newly hired AP with an experienced AP.

b. 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 client who has renal failure. The client tells the nurse that they have decided to stop hemodialysis treatment. Which of the following actions should the nurse take to act in the role of an advocate for the client? a. Inform the client that many clients receiving hemodialysis face discouragement. b. Support the client's decision regarding treatment. c. Tell the client that they made the right decision. d. Suggest that the client's family advocate for continued treatment.

b. Support the client's decision regarding treatment. The nurse's role as client advocate is to support the client's decision to discontinue treatment.

A nurse is caring for a client who is 3 days postoperative following open heart surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report? a. The client's dressing change schedule. b. The client's level of consciousness. c. The client's vital signs from the previous shift. d. The client's occupation.

b. The client's level of consciousness. The nurse should include objective data regarding the client's current consciousness status in the verbal report.

A charge nurse is reviewing the plan of care for a client who has active herpes simplex lesions. Which of the following interventions is appropriate for the plan of care? a. Admit the client to a private room with negative-pressure airflow. b. Wear a gown and gloves when caring for the client. c. Have the client wear a mask during transport. d. Wear a face mask and eye protection when caring for the client.

b. Wear a gown and gloves when caring for the client. The nurse should use contact precautions when caring for clients who have an infection from herpes simplex. Barriers with gloves and gowns are mandatory.

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client that the nurse should assess first? a. "The client who had abdominal surgery 3 days ago is reporting feeling constipated." b. "The client who had the hip replacement reports pain as 4 on a scale of 0 to 10." c. "The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void." d. "The client who is scheduled for discharge today states they are ready to sign their paperwork."

c. "The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void." Not voiding for 6 to 8 hr after indwelling urinary catheter removal indicates this client is at risk for urinary retention, which can cause a urinary tract infection. Overdistention of the bladder can cause damage to the mucosa. Therefore, the nurse should assess this client first and report findings to the provider.

A nurse in the emergency department is performing triage for a group of clients following a motor-vehicle crash. Which of the following clients should the nurse request the provider assess first? a. A client who has a closed leg fracture and reports peripheral paresthesia. b. A client who reports a sprained ankle and has a laceration over the medial ankle. c. A client who has arm contusions and manifests asymmetrical thoracic movement. d. A client who has abrasions to the face and is requesting medication for severe pain.

c. A client who has arm contusions and manifests asymmetrical thoracic movement. A client who has asymmetry of the thorax likely has a tension pneumothorax and requires immediate intervention for survival. Therefore, when using the survival approach to client care, the nurse should request the provider to assess this client first.

A nurse is caring for a client who has an informed consent form for an upcoming procedure in their health record. Which of the following actions should the nurse take to validate that the client understands the procedure? a. Review documentation by the provider of discussing the procedure with the client. b. Verify that the client's signature is on the informed consent form. c. Ask the client to verbalize the purpose, risks, and benefits of the procedure. d. Document the client's completed pre-procedure checklist in the medical record.

c. Ask the client to verbalize the purpose, risks, and benefits of the procedure. The client understands the procedure when they can verbalize the purpose, risks, and benefits of the procedure.

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next? a. Set target dates for completion. b. Identify areas of support. c. Determine goals and objectives. d. Implement recommended strategies.

c. 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. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that they will not have the surgery. Which of the following actions should the nurse take? a. Inform the client of the consequences of decreased cerebral circulation. b. Initiate a mental health consultation to determine why the client is refusing the surgery. c. Discuss the client's concerns about having the surgery. d. Provide the client with information on additional treatment options.

c. 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 facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take? a. Take extra wheelchairs to the emergency department. b. Send PACU assistive personnel (AP) to assist with triage. c. Identify stable clients for transfer to a surgical unit. d. Report to the command center for further instructions.

c. Identify stable clients for transfer to a surgical unit. It is within the charge nurse's scope of practice to identify stable clients for transfer to a surgical unit. This action will enable the facility to do the most good for the greatest number of clients.

A nurse assumes care of a client following change-of-shift report. Which of the following actions should the nurse take? a. Administer the client's insulin as prescribed. b. Give the NPH insulin and hold the regular insulin until the basic metabolic panel (BMP) results are back. c. Obtain a capillary blood glucose reading. d. Hold the client's breakfast until the basic metabolic panel (BMP)......

c. Obtain a capillary blood glucose reading. The nurse should obtain a blood glucose reading to decide whether the prescribed insulin can be safely administered before the meal.

A charge nurse is managing conflict with a staff nurse who does not agree with the client care assignment. Which of the following statements example of using the conflict resolution strategy known as smoothing? a. "Would you accept the assignment if we reassign your client who has total care needs and assign another client who can provide more self-care?" b. "Tell me what changes we need to make so that you'll feel comfortable with the assignment." c. "I didn't mean to make you feel overwhelmed. Why don't you look over the assignments with me and suggest changes?" d. "You always complete your work on time and do a great job. I believe you can handle the assignment well."

d. "You always complete your work on time and do a great job. I believe you can handle the assignment well." The charge nurse is using smoothing as a conflict resolution strategy by complimenting or focusing on shared ideas to reduce the emotional component of the conflict.

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. A client who is in balanced skeletal traction. b. A client who had a total hip arthroplasty 3 days ago. c. A client who has a fractured femur with a new cast d. A client who had a right above-the-knee amputation 24 hr ago.

d. 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 client on a general surgical unit tells a nurse that staff members are not answering the call light promptly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first? a. Notify the charge nurse of the client's request for transfer. b. Assure the client that their concern has been shared with the staff. c. Tell the client that future calls will be answered in a timely manner. d. Ask the client to verbalize their expectations.

d. 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 is witnessing a client sign the consent form for a surgical procedure. The client has a question regarding alternative treatments. Which of the following actions should the nurse take? a. Review the surgical procedure described on the consent form with the client. b. Provide the client with educational materials about the procedure. c. Answer the client's question and have the client sign the consent form. d. Call the surgeon to discuss alternative treatments with the client.

d. Call the surgeon to discuss alternative treatments with the client. It is the provider's responsibility to discuss alternative treatments. Therefore, the nurse should contact the surgeon to answer the client's questions about alternative treatments.

A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take? a. Provide information about alternate birth control methods. b. Ask if the client has discussed the decision with their partner. c. Emphasize the benefits of having the procedure. d. Discuss the client's feelings about the procedure.

d. Discuss the client's feelings about the procedure. The nurse should encourage the client to discuss any feelings or concerns about the procedure.

A nurse is reprimanded by a provider in front of a client. Which of the following actions should the nurse take to resolve this conflict? a. Apologize to the provider to prevent further confrontation. b. Explain the provider's behavior to the client. c. Ask the nurse manager to advocate for proper treatment by the provider. d. Discuss the situation with the provider in private.

d. Discuss the situation with the provider in private. Discussing the situation with the provider in private will enhance mutual understanding and clarification and is an effective communication technique for resolving the interpersonal conflict.

A client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a peripherally inserted central catheter (PICC) line. Which of the following actions should the case manager perform prior to discharge? a. Assess the client's home environment for possible reservoirs of infection. b. Verify the patency of the PICC line. c. Provide dressing change and wound assessment teaching. d. Ensure that home infusion therapy has been arranged.

d. Ensure that home infusion therapy has been arranged. It is the case manager's responsibility to ensure that all necessary referrals have been made to facilitate the client's transition to home care.

A facility has identified an increase in health care-associated urinary tract infections (UTIs) on the medical-surgical unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process? a. Determine the effectiveness of planned interventions. b. Implement strategies to decrease the incidence of UTIs. c. Develop a plan that outlines the process for data collection. d. Establish best practice guidelines for reducing the incidence of UTIs.

d. Establish best practice guidelines for reducing the incidence of UTIs. Evidence-based practice indicates the nurse should first establish best practice guidelines for reducing the incidence of UTIs in order to have a standard to measure performance.

Two nurses on a unit each contend that the other is not doing a fair share of work. The conflict is affecting the functioning of the unit. A charge nurse should approach this conflict in which of the following ways? a. Schedule the nurses to work on alternating shifts. b. Organize a task force to evaluate the situation c. Tell the nurses that it is their responsibility to cooperate with coworkers. d. Explore alternative solutions to address unit workflow with the nurses.

d. 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 nurse has 4 client assignments on a maternal newborn unit. Which of the following tasks can be delegated to an assistive personnel (AP)? a. Palpating the client's fundal height. b. Teaching the client how to perform cord care. c. Assessing the client's vaginal bleeding. d. Measuring urine output of the client's first voiding.

d. Measuring urine output of the client's first voiding. The nurse should delegate the AP to measure urine output of the client's first voiding because it is within the AP's scope of practice.

A nurse on a medical-surgical unit is planning care for a client who has dementia and is being admitted for surgery. Which of the following actions should the nurse take to promote client safety? a. Obtain a prescription for limb restraints b. Leave the television on for background noise. c. Maintain 4 side rails in a raised position on the client's bed. d. Place the client in a room near the nurses' station.

d. Place the client in a room near the nurses' station. The nurse should place the client in a room near the nurses' station and observe the client frequently to reduce the risk of injury.

A nurse at an urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take to ensure care is provided according to policy? a. Check client satisfaction surveys for feedback on this issue. b. Post an article on pain assessment on the bulletin board c. Document this finding on an incident report. d. Report this issue to the nurse manager.

d. Report this issue to the nurse manager. The nurse should report this issue to the nurse manager because it is the manager's responsibility to ensure that standards are met and that care is provided according to policy.

A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take? a. Insert the tube and begin feedings per the family's request. b. Ask the provider to discuss the issue with the family. c. Report the dilemma to the facility's dietitian. d. Review the client's request with the family. The client's living will states that artificial enteral feedings should not be allowed, and the nurse should review the client's request with the family. Staff members should use the client's living will as the guide for treatment unless a durable power of attorney for health care has been created.

d. Review the client's request with the family. The client's living will states that artificial enteral feedings should not be allowed, and the nurse should review the client's request with the family. Staff members should use the client's living will as the guide for treatment unless a durable power of attorney for health care has been created.

A nurse is reviewing facility data on hand hygiene adherence and finds that nurses are not performing hand hygiene after client contact 28% of the time. Which of the following is the first action the nurse should take when developing a plan to increase employee hand hygiene adherence? a. Schedule training sessions to teach proper technique. b. Provide alcohol-based hand wash outside of each client's room. c. Identify a way to measure hand hygiene adherence. d. Set a goal for improvement in adherence.

d. Set a goal for improvement in adherence. The nurse should set a goal against which nursing care is measured when planning health care improvement. Therefore, this is the first action the nurse should take.

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult when planning for this policy? a. National League for Nursing (NLN) b. American Academy of Nursing (AAN) c. Agency for Healthcare Research and Quality (AHRQ) d. State Nurse Practice Act (NPA)

d. State Nurse Practice Act (NPA) The nurse should consult the NPA in this situation because the PA defines the scope and boundaries of professional nursing practice. The PA provides guidelines for developing standardized procedures within specific facilities where expanded nursing functions have been approved in collaboration with nurses, providers, and administration.

An RN is assigning tasks to team members. Which of the following tasks is appropriate to delegate to a licensed practical nurse (LPN)? a. Complete a client's admission assessment. b. Titrate the flow of diltiazem IV for a client who is in a hypertensive crisis. c. Develop a teaching plan for a client who was recently diagnosed with diabetes mellitus. d. Suction a client who has a chronic tracheostomy.

d. Suction a client who has a chronic tracheostomy. Suctioning a client who has a tracheostomy is within the LP's scope of practice. The RN should determine the LPN's competency and the stability of the client when considering delegation of this task.

Which of the following findings should the nurse identify require follow-up by the provider? Select the 6 findings that require immediate follow-up. Exhibit 1: Day 1, 1715: Client is 6 hr postoperative following abdominal surgery. Client is resting and easily awakened. Alert and oriented to person, place, and time. Incision has moderate amount of serous sanguineous draining on dressing. Abdominal dressing is intact. States pain level is a 4 on a 0 to 10 pain scale. Bowel sounds are normoactive. Client tolerating sips of water. Urinary output 320 mL in last 4hr. Day 1, 2030: Nurse enters room client's room. Client is restless and short of breath. Client rates pain as an 8 on a scale of 0 to 10, saying, "My abdomen hurts so bad." Nurse notes dressing site has large amounts of bright red blood. -Blood pressure -Bowel sounds -Pain level -Respiratory rate -Urinary output -Heart rate -Orientation status -Oxygen saturation

When analyzing cues, the nurse should identify that an increase in heart rate, respiratory rate, a pain level of 8 on a scale of 0 to 10, a large amount of bright red blood on the client's abdominal dressing, along with a decrease in blood pressure and oxygenation saturation are manifestations of hemorrhage. Therefore, the nurse should notify the client's provider of these findings immediately.

A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take? a. Place the client in a dorsal recumbent position for the examination. b. Auscultate for vascular bruits with the diaphragm of the stethoscope. c. Begin the assessment by using light palpation over the abdomen. d. Ensure that the client has a full bladder before beginning the procedure.

a. 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 their abdominal muscles.

A nurse manager is conducting an annual performance review for a staff nurse. Which of the following strategies should the nurse use in the review process? -Evaluate the nurse's performance based on a comparison of the nurse to others on the unit. -Complete a performance checklist. -Have the nurse conduct a self-appraisal prior to the review. -Include peer evaluations completed by other staff nurses. -Base the review on the nurse's performance during the past 90 days.

Base the review on the nurse's performance during the past 90 days is incorrect. The nurse manager should collect data throughout the year to include in an annual performance review. Include peer evaluations completed by other staff nurses is correct. The nurse manager should include peer evaluations when reviewing the nurse's work performance. Evaluate the nurse's performance based on a comparison of the nurse to others on the unit is incorrect. The nurse manager should evaluate the nurse against an established set of standards, not against the performance of other nurses on the unit. Have the nurse conduct a self-appraisal prior to the review is correct. The nurse manager should include the nurse's self-appraisal in the review process because it encourages the nurse to reflect on their own performance and make plans for improvement. Complete a performance checklist is correct. The nurse manager should conduct a performance checklist to evaluate the nurse's work performance.

The nurse is evaluating the client's plan of care. Which of the following findings indicate that the client's condition is worsening and the plan of care should be updated? Select all that apply. -Oxygen saturation -Respiratory rate -Blood pressure -Bowel sounds -Sputum -Temperature -Heart rate

When evaluating the client's plan of care the nurse should identify that blood-tinged sputum, an increase in temperature, heart rate, respiratory rate, and a decrease in oxygen saturation indicates the client's pneumonia is worsening. Therefore, the nurse should contact the provider for further instructions.

The nurse is reviewing the client's plan of care. Which of the following findings require notification of the provider? Select all that apply. -Temperature -Blood pressure -Potassium level -Oxygen saturation -WBC count -Prealbumin level -Heart rate -Pain level

When planning client care, the nurse should identify that an increase in heart rate, temperature, and WBC count, along with a decrease in blood pressure and prealbumin level, can indicate an increase in infection of the client's wound that can lead to sepsis. Therefore, the nurse should notify these findings to the provider for further intervention.

Select the employee findings that the nurse manager should identify as a concern for employee substance use disorder. Select all that apply. -Results of annual review -Client statement -Hygiene -Change in social habits -Mood changes -Charting -Attendance

When recognizing cues the nurse manager should identify changes in the employee's attendance, rapid mood changes, social isolation, sudden change in personal hygiene, and complaints from clients that their pain medication is ineffective as findings which may indicate a substance use disorder. The nurse's behavior needs to be further investigated. Additional findings of substance abuse in the employee may include errors in judgement, drowsiness, and episodes of euphoria. Due to the immediate safety hazard, the nurse manager should remove the nurse from the unit and client care immediately.

Select 1 action the nurse manager should take during the meeting between the 2 nurses to achieve a win-win resolution. -Encourage the nurses to accommodate one another to reduce conflict. -Encourage the nurses to smooth over the conflict with their colleague. -Encourage the nurses to compete for their desired conflict resolution outcome. -Encourage the nurses to avoid interacting with one another to reduce conflict. -Encourage the nurses to collaborate with one another to address the conflict.

When taking actions, the nurse manager should identify collaboration as a conflict resolution strategy that achieves a win win resolution. Collaboration involves both individuals working together to achieve a common goal. Using this conflict resolution strategy, both individuals achieve their goal through setting new goals as a team.

A charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects an intrapersonal conflict? a. "I'm not sure whether I want to apply for the unit manager's position or start a family this year." b. "I feel frustrated because I just readmitted a client who refuses to take their insulin." c. "The unit manager is more concerned with saving money than with clients getting quality care." d. "Every time I request an extra day off I'm denied, but other nurses' requests are approved."

a. "I'm not sure whether I want to apply for the unit manager's position or start a family this year." The nurse's statement indicates an intrapersonal conflict because the nurse is struggling with competing personal and professional values and desires.

A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? a. A nurse is photocopying their assigned client's diagnostic test results. b. An assistive personnel (AP) documents a client's vital signs on the client's paper-based graphic record. c. The unit secretary faxes a client's laboratory results to the provider. d. An RN stays with a client who is reading the medical records that were requested.

a. A nurse is photocopying their assigned client's diagnostic test results. Photocopying diagnostic test results is a breach of the client's confidentiality and privacy.

A nurse manager is planning daily work and activities for the unit. Which of the following actions is the nurse manager's priority? a. Assign client care to staff. b. Coordinate staff breaks. c. Organize daily meetings using an appointment book. d. Review long-term goals of the unit.

a. Assign client care to staff. When using the urgent vs nonurgent approach to client care, the nurse determines that the priority action is to assign client care to staff. This ensures continuity of care and that clients receive prescribed treatments in a timely manner.

A nurse is caring for several clients. Which of the following actions should the nurse take to maintain client confidentiality? a. Tell a client's partner that the client's laboratory tests cannot be disclosed without permission. b. Ask the assistive personnel (AP) to refer to clients by room number in public areas. c. Explain to a nursing student that verbal permission must be obtained before using a client's name in school assignments. d. Share information about a client with members after personal identification has been provided.

a. Tell a client's partner that the client's laboratory tests cannot be disclosed without permission. This action by the nurse will maintain client confidentiality. Providing a client's partner with laboratory results without permission is unauthorized disclosure of confidential information.

Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)? a. "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122." b. "Check the urinary output at 1100 for John Doe and report it to me immediately." c. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438." d. "Please notify me of any clients whose vital signs or blood glucose levels are significant."

b. "Check the urinary output at 1100 for John Doe and report it to me immediately." This instruction follows the Five Rights of Delegation by practicing the requirements for right direction/communication, which includes the data to collect, client-specific information, a timeline for collection, and the expectation for communicating the findings back to the nurse.

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)? a. Determine the swallowing ability of a client who has had a stroke. b. Provide an enteral feeding to a client who has Crohn's disease. c. Develop a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. d. Weigh a client who is 3 days postoperative following coronary artery bypass grafting.

b. 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 LP. Therefore, it is appropriate for the charge nurse to assign this task to an LPN.

A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "I should place a copy of an incident report in the client's medical record." b. "I should document the completion of an incident report in the client's medical record." c. "I should complete an incident report for an unexpected client occurrence." d. "I should ask the risk manager to complete the incident reports."

c. "I should complete an incident report for an unexpected client occurrence." The nurse should complete an incident report for unexpected occurrences to assist in determining causes of deviations from standards of care.

A nurse in a mental health facility is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? a. "I should use mechanical restraints when a client who is manic starts pacing." b. "I should document every hour when a client is in mechanical restraints." c. "I should request the provider to examine the client within 1 hour of applying mechanical restraints." d. "I should check the client every 30 minutes while in mechanical restraints."

c. "I should request the provider to examine the client within 1 hour of applying mechanical restraints." The provider should evaluate the client within 1 hr of initiation of the mechanical restraint.

A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures? a. Removal of staples from a surgical wound. b. Providing a sputum specimen. c. Receiving moderate sedation. d. Collection of a blood specimen for ABGs.

c. 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 is caring for a school-age client who is seeking treatment for a laceration to the right forearm that occurred during soccer practice. The client was transported to the emergency department by a friend's parent and the soccer coach. The nurse should ensure that informed consent is given by which of the following people? a. The client b. The friend's parent c. The client's guardian d. The soccer coach

c. The client's guardian The parent or legal guardian is authorized to give consent for the client.

A home health nurse is performing a home safety assessment for a family who has a toddler. Which of the following findings is a potential environmental hazard the nurse should discuss with the parents? a. The crib mattress is positioned at the lowest level. b. The toy box does not have a hinged lid. c. The toilet seat lid is in the raised position. d. There is a throw rug under the toddler's crib.

c. The toilet seat lid is in the raised position. Accidental drowning can occur if the toilet seat lid is raised.

A nurse manager is reviewing the actions a staff nurse took when they observed smoke coming from a wastebasket in a client's room. The nurse manager should verify that the nurse acted appropriately when they performed which of the following actions first? a. Closed the door to the client's room b. Initiated the fire alarm system c. Transported the client to the hallway d. Attempted to extinguish the fire

c. Transported the client to the hallway The greatest risk to this client is injury from a fire. Therefore, the first action the nurse should take using the RACE protocol is to remove the client from the area of danger.

A client presents to an emergency department reporting back pain and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make? a. "It sounds like nonpharmacological interventions would be best for this client." b. "Let's withhold the oxycodone until we can consult with the provider." c. "Contact mental health services to arrange for a consultation." d. "Clients are the experts on their own pain."

d. "Clients are the experts on their own pain." 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 assumerions

A nurse is teaching an assistive personnel (AP) about caring for a client who has a do-not-resuscitate (DR) order. Which of the following statements by the AP indicates an understanding of the teaching? a. "If I cannot detect the client's pulse, I will have another AP verify this with me." b. "If the client does not have a pulse, I will call for the rapid response team. c. "I will initiate CPR until a nurse arrives if I cannot detect the client's pulse." d. "I will call for the client's nurse to come to the room if I cannot detect the client's pulse."

d. "I will call for the client's nurse to come to the room if I cannot detect the client's pulse." The AP should contact the nurse for further assessment whenever a client's condition does not meet expected findings. The client who has a DR order in place does not require resuscitation.

The nurse is reviewing the client's medical record. Which of the following findings should the nurse identify require immediate follow-up? Select 4 findings that require immediate follow-up. -Weakness -Nausea -Diaphoresis -ECG results -Oxygen saturation -Blood pressure -Respiratory rate

When using the airway, breathing, circulation plan of care to prioritize hypothesis for the client, the nurse should identify the client is experiencing angina. Therefore, the nurse should report the client's increase in respiratory rate, blood pressure, a decrease in oxygen saturation level along with the client's ECG results to the provider immediately for further intervention.

An assistive personnel (AP) tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent. Which of the following responses should the charge nurse make? a. "'I delegate tasks to personnel based on their job descriptions." b. "Everyone working here has to care for clients who are incontinent." c. "Let's talk about organizing the workflow so you care for fewer of these clients." d. "Why do you not want to care for clients who are incontinent?"

a. "'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 receives notification of a fire on the unit. Which of the following actions should the nurse take first? a. Assist clients who are in immediate danger to a safe location. b. Close doors and windows on the unit. c. Attempt to extinguish the fire using an ABC fire extinguisher. d. Discontinue oxygen use for clients who can breathe without it.

a. 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.