(2) - RN Concept-Based Assessments Level 4 Online Practice B - (2)

A nurse manager is discussing professional liability during a staff presentation. In which of the following situations can the assigned nurse be held professionally liable if the client is harmed?

- charge nurse insists a staff nurse reposition a sutured NG tube on a client following bariatric surgery, and the client has to return to surgery - nurse administers warfarin per the provider's prescription to a client who has an INR for 4.3 - a client experiences an arrhythmia while the nurse tries for several hours to report potassium of 3 mEq/: to the provider but does not notify the charge nurse

A case manager is planning care for a middle adult client who was moderately injured during a work accident. The client has dependent children and reports needing financial assistance to pay for healthcare. Which of the following resources should the case manager recommend?

- medicaid - state worker's compensation board - local health department

A nurse is assessing a client who has advanced-stage cirrhosis. Which of the following findings should the nurse expect?

- petechiae - pruritus - hemorrhoids

A nurse is teaching a newly licensed nurse how to perform assisted coughing for a client who has a spinal cord injury. In what order should the nurse perform the following steps?

- place hands on the client's upper abdomen with fingers interlocked - instruct the client to take a breath and then cough while exhaling - lock the elbows - push hands inwards and upwards - allow the client to rest

A nurse is evaluating QI tools at a facility. When reviewing information about clients who had sepsis, which of the following data should the nurse identify as indicating improved client outcomes?

an increase in the number of clients who did not require vasopressor administration to treat a MAP above 65

A nurse is caring for a client who has bipolar disorder. Which of the following actions indicates the nurse is respecting the client's right to privacy?

asking family members to leave the room before the medical history is collected from the client

A nurse is providing teaching to a client who has a new prescription for captopril to treat heart failure. Which of the following instructions should the nurse include?

report a nonproductive cough - adverse effect

A nurse in a primary care clinic is examining the ECG tracing of a client who reports fatigue and palpitations. The nurse notices no visible P waves, no atrial contractions, a wavy baseline, and an irregular ventricular rate. Which of the following dysrhythmias should the nurse identify?

atrial fibrillation - irregular

A nurse is teaching about home care with the guardian of a child who has thrombocytopenia and a platelet count of 40,000. Which of the following statements by the guardian indicates an understanding of the teaching?

i will give my child acetaminophen when she is having pain

A public health nurse is investigating a potential outbreak of measles in the community. Which of the following agencies should the nurse identify as a resource for reporting a potentially infectious outbreak of measles?

CDC

A nurse manager is developing an in-service for staff members about emergency medical treatment and active labor act (EMTALA). Which of the following information should the nurse manager include?

EMTALA violations can lead to the loss of medicare payments

A nurse is reviewing the medical record of a client who has sepsis and is experiencing septic shock. Which of the following findings should the nurse expect?

HR 116 - compensatory - FVE for septic shock

A nurse who is following the chain of command reports an ongoing issue regarding a documented unsafe client care practice to her nurse manager. Which of the following responses should the nurse manager make?

i will work with you to take this issue to the next level as we attempt to enact change

A nurse is applying debriding enzymes to a client's stage IV pressure ulcer. Which of the following actions should the nurse take?

secure the dressing over the ulcer with tape

A nurse is assessing an adolescent who is experiencing hypovolemic shock. Which of the following findings should the nurse expect?

RR 26

A charge nurse is discussing accrediting organizations for health care facilities with a newly licensed nurse. Which of the following statements about the joint commission should the charge nurse make?

TJC requires to follow quality improvement initiatives

A nurse is reviewing laboratory reports for a client who has sepsis and has been receiving IV antibiotics for 2 days. Which of the following laboratory results should the nurse report to the provider immediately?

WBC 45,000

A nurse is receiving change-of-shift report about four clients. For which of the following clients should the nurse suspect physical abuse?

a 3 year old child who has a burn on the sole of the right foot

A public health nurse is leading an inservice about types of health care services in the community. Which of the following should the nurse include as an example of secondary care?

a client in a diagnostic center who is receiving a CT scan to check for a tumor

A charge nurse is discussing sentinel events with a newly licensed nurse. Which of the following examples should the nurse provide as a sentinel event?

a client who falls experiences a subarachnoid hemorrhage

A nurse is performing mass casualty triage following a disaster. To which of the following clients should the nurse assign a black tag?

a client who has a penetrating head wound and agonal respirations

A nurse at a community health clinic is assisting in the mass casualty triage of clients following an explosion. To which of the following clients should the nurse assign a green tag?

a client who has an upper extremity closed fracture

A nurse is caring for a group of clients on a med/surg unit. Which of the following client situations should the nurse report to the charge nurse as a near miss?

a client who is NPO receives a meal tray and the AP removes it before the client eats or drinks anything

A nurse manager at a home health facility is preparing an in-service about legal guidelines. Which of the following situations should the nurse plan to include as an example of medical malpractice?

a nurse forgets to request PT services for a client who has weakness and the client falls

A charge nurse is supervising a group of staff on the unit. Which of the following actions should the charge nurse identify as a potential professional liability?

a nurse requests to perform the narcotic count every shift

A nurse manager is teaching a group of newly licensed nurses about clients having autonomy. Which of the following examples should the nurse manager include that demonstrates this ethical principle?

a nurse respects a client's decision to refuse the administration of blood due to religious beliefs

A nurse is assessing a client who has a SCI and is experiencing autonomic dysreflexia. Which of the following manifestations should the nurse expect?

severe headache

A nurse is planning care for a client who is being admitted with a major burn injury over 40% of the total body surface area. Which of the following interventions should the nurse include in the plan?

administer continuous IV fluids for 24 hrs - no bolus

A nurse is caring for a client who has developed cardiogenic shock. Which of the following actions is the nurse's priority?

administer oxygen

A nurse is planning care for a client who is postoperative following abdominal surgery. According to research-based care, which of the following interventions should the nurse include in the plan to prevent a DVT?

administer prophylactic anticoagulation medication to the client - ROM Q1H

A nurse is teaching a group of unit nurses about lung surfactant therapy to treat respiratory distress syndrome in preterm newborns. Which of the following information should the nurse include?

administer the medication via endotracheal instillation

A nurse is reviewing the medical record of a client who has MI and is to undergo a cardiac catheterization. Which of the following information should the nurse report to the provider prior to the procedure?

allergies

A nurse is planning an in-service for nursing staff about preventing CAUTIs. After identifying learning objectives, which of the following actions should the nurse take next?

identify current research demonstrating best practices for preventing CAUTIs

A nurse in an ED is caring for a client who has persistent supraventricular tachycardia with manifestations of SOB and syncope. Which of the following medications should the nurse expect the provider to prescribe to convert this dysrhythmias to a normal sinus rhythm?

adenosine - fast

A nurse is caring for a child who has bacterial meningitis with increased intracranial pressure. Which of the following actions should the nurse take?

administer acetaminophen with codeine for pain - droplet precautions

A charge nurse on a medical-surgical unit is working with a LPN. Which of the following tasks should the nurse assign to the LPN?

administer an IM pain medication to a postoperative client

A nurse is providing education for a female adolescent regarding self-management of lupus. Which of the following information should the nurse include?

increase consumption of calcium-rich foods - osteoporosis

A nurse is assessing a client who has hepatic encephalopathy and a serum ammonia level of 110 mcg/dL. Which of the following images depicts the test the nurse should implement to determine whether the client is in stage IV of hepatic encephalopathy?

babinski reflex

A nurse is caring for a preterm newborn who was born at 31 weeks of gestation and has respiratory distress syndrome. Which of the following medications should the nurse expect the provider to prescribe?

beractant - artificial surfactant

A nurse is developing a plan for a client who has urinary incontinence. Which of the following bladder training interventions should the nurse include to reduce incontinence?

increase intervals times each day once the client remains continent between intervals - 3-6 hrs

A nurse is updating the discharge plan for a client who is ventilator-dependent and will be transferred to a long-term care facility. To facilitate the coordination of the transfer, the nurse should contact which of the following members of the health care team?

case manager

A nurse is discussing the concept of case management with a newly licensed nurse. Which of the following information should the nurse include?

case managers contribute to managing the costs of a client's health care

A nurse is assessing a client who has a brain tumor. The client has difficulty balancing due to poor muscle coordination and the nurse detects nystagmus. The nurse should recognize that the brain tumor is affecting the following area of the brain?

cerebellum

A nurse in the ED is caring for a client who sustained major burns in a house fire. Which of the following interventions is the nurse's priority?

check for singed nasal hairs

A nurse manager discovers that the unit is over budget for the quarter. Which of the following actions should the nurse manager plan to provide more cost-effective care?

consider labor requirements during the past year before determining staffing needs

A nurse manager is planning to assist two staff members involved in a client by using the conflict management strategy of third-party consultation. Which of the following actions should the nurse manager plan to take?

consider the assistance of outside experts for highly emotional situations

A nurse is providing an in-service for a group of newly licensed nurses about professional characteristics. Which of the following should the nurse include as an example of the nursing value of altruism?

considers the well-being of coworkers - taking actions that take into account the needs and well-being of others

A nurse is assessing a client who has AIDS. The client reports persistent diarrhea with rapid weight loss. Which of the following opportunistic infections should the nurse suspect?

cryptosporidiosis

A nurse is developing a plan of care for a toddler who has heart failure and is receiving furosemide. Which of the following actions should the nurse include in the plan?

increase the toddler's intake of foods high in potassium

A nurse is caring for a client who has hypercortisolism. Which of the following laboratory findings should the nurse expect?

increased blood glucose level

A nurse is assessing a client who has cushing's disease. Which of the following manifestations should the nurse expect?

increased blood pressure - b/c retain Na and H2O

A nurse manager is conducting QI audits for the unit. Which of the following findings requires further evaluation?

increased client falls

A nurse is assessing a client who has encephalitis. The nurse should identify that which of the following finding is an indication of increasing intracranial pressure?

increased pupil size

A nurse is planning care for a newborn whose mother has HIV. Which of the following actions should the nurse plan to take?

delay administration of phytonadione until the newborn has been bathed - prevent transmission of HIV

A nurse manager is teaching about emergency preparedness to a group of newly licensed nurses for clients who experience mental health crises following a disaster. Which of the following actions should the nurse include in the teaching as the first step to take when caring for these clients?

determine the client's level of precrisis functioning

A public health nurse is participating in the recovery phase of emergency response to a hurricane. Which of the following actions should the nurse take first?

determine the needs of the community

A nurse is assessing a client who is a resident of a halfway house for clients who have mental health disorders. The client has patterned bruising to the torso and arms. Which of the following actions should the nurse take first?

develop rapport with the client

A nurse is working on a postpartum unit to implement 24 hour rooming-in for mothers and their infants. Which of the following actions by the nurse demonstrates the preparation stage of the stages-of-change model?

developing a presentation for staff members about 24 rooming-in

A nurse is assessing a client who has lupus. Which of the following manifestations should the nurse expect?

dry, scaly rash over the nose and cheeks

A nurse is reviewing the medical record of a client who has cirrhosis due to liver disease. Which of the following laboratory findings should the nurse expect?

elevated serum bilirubin - can't excrete

A nurse is reviewing the medical record for a client who has Addison's disease. Which of the following laboratory results should the nurse expect?

fasting blood glucose 62

A nurse is assessing a client who has a stage II pressure ulcer. Which of the following findings should the nurse expect?

full-thickness tissue loss iwht visible subcutaneous fat

A nurse manager is preparing to use collaboration to resolve a conflict between two nurses. Which of the following actions should the nurse manager plan to take?

have both parties share decision-making to meet common goals

A nurse is assessing a client following surgery. For which of the following manifestations should the nurse suspect that the client has a pulmonary embolism?

hemoptysis

A nurse is discussing hepatitis C with a newly licensed nurse. Which of the following information should the nurse include?

hepatitis C frequently results in a chronic infection

A nurse is teaching a client who has just undergone the insertion of a permanent pacemaker because of a sinus dysrhythmia. Which of the following instructions should the nurse include?

hold cell phones to the ear on the opposite side of the pacemaker

A staff nurse who is upset approaches a charge nurse about concerns related to providing care to a group of clients. Which of the following statements should the charge nurse make when using assertive communication?

i am willing to discuss this issue privately in my office

A nurse is caring for a client who is experiencing chronic pain due to terminal cancer. The client asks the nurse to administer an injection to help him die. Which of the following responses should the nurse make regarding this ethical dilemma?

i can assist you with establishing advance directives that will clarify your end-of-life wishes

A nurse is teaching a client who has AIDS about self-management strategies for preventing infection. Which of the following client statements indicates an understanding of the teaching?

i should not share deodorant sticks with others

A nurse is providing discharge teaching to the parent of a preschooler who experienced a minor head injury after a fall. Which of the following statements by the parent indicates an understanding of the teaching?

i should notify the provider if my child develops a runny nose in the next several days

A nurse is contemplating accepting a nursing leadership role as a charge nurse on his unit. Which of the following statements by the nurse indicates an understanding of a charge nurse's role?

i should review the facility's chain of command and invoke the process when needed

A nurse manager notices that a nurse has slurred speech and smells of alcohol. Which of the following actions should the nurse manager take first?

remove the nurse from the client-care work environment

A nurse in an ED is triaging an older adult female client who has a history of coronary artery disease. The client reporting vague manifestations but no chest pain. Which of the following findings should the nurse identify as a possible manifestation of an acute MI?

indigestion - not low back pain

A nurse manager is conducting an in-service about hepatitis A for a group of nurses. Which of the following information should the nurse manager include as a risk factor for acquiring the hepatitis A virus?

ingesting shellfish

A nurse is planning care for a client who is experiencing an Addisonian crisis and has hyperkalemia. According to research-based care, which of the following interventions should the nurse include in the plan?

initiate cardiac monitoring of the client

A nurse is caring for a newborn who was delivered after a prolonged rupture of membranes. Which of the following newborn assessment findings should the nurse report to the provider?

intercostal retractions

A nurse is planning a presentation about professional nursing organizations. Which of the following information should the nurse include about the ANA?

it develops professional standards for nursing practice

A nurse is providing teaching to a client who has polycystic kidney disease. Which of the following disease management instructions should the nurse include?

keep track of your bowel movements - pressure on bowels

A public health nurse is reviewing the roles of local, state, and national agencies in emergency response. After first responders are dispatched to the site of an incident, which of the following actions should the nurse expect to occur next?

local officials activate the local emergency operations center

A nurse is planning care for an infant who has bronchiolitis caused by respiratory syncytial virus (RSV). Which of the following interventions should the nurse include?

maintain oxygen saturation at 90% or greater - bronchodilator no help

A nurse is teaching a group of clients about degenerative disk disease. Which of the following information should the nurse include regarding the prevention of low back pain and injury?

maintain weight within 10% of ideal body weight

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 50,000. Which of the following actions should the nurse take?

measure the client's abdominal girth daily - check Q4H for bleeding

A nurse is planning care for a child following replacement of a ventriculoperitoneal shunt for treatment of ICP. Which of the following interventions should the nurse include in the plan?

monitor the child for abdominal distention (in abdomen) - supine position

A nurse is assessing a client who has a brain tumor. Which of the following findings should the nurse expect?

morning headache

A nurse in the ED is caring for a client who is experiencing an acute MI and reports chest pain that has an intensity of 8 on a scale of 0-10. Which of the following medications is the nurse's priority to administer to this client?

morphine - MONA

A nurse working in an industrial facility is providing care for a worker who experienced a hazardous chemical exposure. To which regulatory agency must the nurse report this incident?

occupational safety and health agency (OSHA)

A nurse manager is reviewing conflict management strategies with a group of nurses. Which of the following statements should the nurse include when discussing the strategy of smoothing?

one party attempts to pacify the other party to minimize emotions

A community mental health nurse is planning strategies to address increased opioid use in the community. Which of the following strategies should the nurse implement as a method of primary prevention?

organizing a town hall assembly to discuss the adverse effects of opioid use

A nurse is delegating client care to an AP. Which of the following tasks should the nurse assign to the AP?

performing chest compressions as a member of the code team

A nurse is developing a plan of care for a client who has a DVT of the left lower leg. Which of the following interventions should the nurse include?

place thigh-high graduated compression stockings on the client's legs

A nurse is reviewing the medical record of a client who has experiencing a T5 spinal cord injury. Which of the following findings should the nurse report to the provider immediately?

platelet count 50,000 - risk for bleeding

A nurse is caring for a client who is immunocompromised and has developed DIC. Which of the following treatments should the nurse expect to administer?

platelets

A nurse is reviewing the medical record of an 11-year-old child who has acute renal failure. Which of the following laboratory results should the nurse expect?

potassium 5.2

A nurse is reviewing the laboratory results for a client who sustained major burns after a motor vehicle crash where a fuel spill ignited. Which of the following laboratory values should the nurse expect during the resuscitation phase of care?

potassium 6.2 - increases from burns

A charge nurse is working on an acute care floor when a natural disaster occurs. Which of the following emergency response actions should the nurse take?

prepare medically stable clients for early discharge

A nurse is reviewing the medical record of a client. Which of the following findings should the nurse identify as a risk factor for developing a DVT?

prescription for oral contraceptives

A nurse is collaborating with a dietitian about the dietary intake of an older adult male client who has a stage IV pressure ulcer. Which of the following adjustments to the client's diet is the priority to provide for optimal wound healing?

protein 2 g/kg/day

A nurse is working at a community health center with clients who have limited socioeconomic resources. Which of the following actions should the nurse take as a primary prevention strategy to address health care disparities for these clients?

provide free influenza immunizations

A nurse is using evidenced based research to develop a critical pathway for clients who have partial-thickness burns. Using the research utilization process, the nurse should identify that which of the following categories represents the best strength of evidence?

systematic review of clinical trails

A nurse in an ICU is assessing a client who has cardiogenic shock resulting from postmyocardial infarction heart failure. Which of the following findings should the nurse expect?

tachypnea

A nurse preceptor is observing a newly hired nurse during orientation to the facility. Which of the following actions by the newly hired nurse should the nurse preceptor identify as fulfilling the role of change agent?

talks with a group of coworkers about the benefits of a provider order entry system

A nurse is discussing the role of the RRT with a newly licensed nurse. Which of the following statements should the nurse make?

the RRT may be activated by a client's family members

A nurse is assessing a client who has multiple fractures due to a motor vehicle crash 2 weeks ago. For which of the following findings should the nurse engage in interprofessional collaboration with the physical therapist?

the client has a nonblanchable, reddened area on the sacrum

A nurse is participating in interprofessional collaboration regarding a client who is to be discharged to home following a stroke. Which of the following information should the nurse provide the OT on the team?

the client is experiencing difficulty using a spoon for self-feeding

A charge nurse is teaching a newly licensed nurse about risk management. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

the risk manager review incident reports to monitor for system flaws

A nurse is reviewing ethical dilemmas with a group of newly licensed nurses. Which of the following information should the nurse include about ethical dilemmas?

the situation requires a choice between multiple ethical principles

A nurse is planning to administer a new medication to a client. The nurse is using which of the following ethical principles when he is truthful about the adverse effects of the medication?

veracity

A nurse is assessing a client who has encephalitis. For which of the following findings should the nurse immediately notify the provider?

widened pulse pressure - increased ICP

A nurse is caring for a client who has parkinson's disease. Which of the following instructions should the nurse include in the teaching about mobility?

you should consider participating in a yoga class - swinging arms is good

A nurse is providing teaching about home care to a parent of a toddler who has CF. Which of the following statements should the nurse include?

you should feed your toddler foods that are high in protein