ATI capstone management pre-assessment

A nurse us reviewing HIPAA with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further instructions?

"Information about a client can be disclosed to family members at any time." The nurse's statement reflects a need for further instructions. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.

A nurse is caring for a client who has heart failure notices that the client did not receive his scheduled dose for furosemide. When filling out an incident report about the occurrence, which of the following information should the nurse include? SATA

-Clients breath sounds clear bilaterally. If a medication error occurs, the nurse should monitor the client for adverse effects. Furosemide is a loop diuretic and is used in clients who have heart failure to help eliminate excess fluid. The client missed a dose of furosemide, so the nurse should monitor for signs of fluid volume excess such as crackles and peripheral edema. -The nurse documents the clients status as a result of the occurrence. Factual information should be included in the incident report with details about the impact on the client. - The client's statement about the occurrence. The client's statement should be included.

A nurse is preparing to administer a medication to a client. Which of the following actions by the nurse demonstrates advocacy for client rights?

Encourage the client to verbalize questions or concerns. The nurse should encourage the client to ask questions and express concerns regarding medications. It is the clients right to be knowledgeable about his health and it is the nurse's responsibility as the client advocate to provide this information.

A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the clients safety, Which of the following actions should the nurse take?

Initiate seizure precautions for the child. A child who has a brain tumor is at risk for seizures. It is imperative for the nurse to implement seizure precaution.

A nurse us caring for a client on a medical-surgical unit who is attempting to leave the facility. Which of the following actions should the nurse take?

Make sure the client understands that he is leaving against medical advice. The nurse should inform the client that leaving is against medical advice (AMA) ask him to sign the facility's AMA form and document the situation in the client's medical record.

A nurse is caring for a client when the safety on the bed plug's electrical outlet pops and begin to smoke. Which of the following actions is the nurse's priority?

Move any client in the immediate vicinity. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. Rescue client, Activate alarm, Confine the fire, and Extinguish the fire.

A nurse is caring for a client who has dementia and is scheduled for a procedure. Which of the following individuals should the nurse request to sign the client's informed consent?

The client's son, who has durable power of attorney A durable power of attorney for health care is a legal document that designees an individual authorized to make health care decisions for a client who is unable.

A nurse in a long-term care facility is reinforcing teaching about safe delegation practice with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

"Delegated tasks require follow-up to ensure compliance." The nurse should include using of the five rights of delegation when assigning tasks to an AP. Right task, right circumstances, right person, right communication, and right supervision. The last right, supervision, requires the nurse to appropriately monitor, evaluate and provide feedback to the AP.

A nurse us reinforcing teaching about delegation to an assistive personnel (AP) with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

"Delegation permits a designated individual to meet a goal on your behalf." The nurse should include that delegation involves transferring responsibility for the performance of a specific task while retaining accountability for the task. It results in quality client care, and improved efficiency and productivity.

A nurse is rehearsing assertive communication approaches to decline leadership of a nursing department committee. Which of the following statements by the nurse demonstrates assertiveness?

"I decline the opportunity at this time." This is an assertive form of communicating because it contains an "I" statement, and is clear and firm.

A nurse is caring for a client who is rehabilitating from injuries resulting from a motor vehicle crash. Which of the following client statements should the nurse identify as the priority?

"I have nit been able to sleep at night because it hurts when I move." When using Maslow's hierarchy of needs, the nurse determines that the priority findings is the client's report of pain and difficulty sleeping. These are physiological needs.

An older adult client about to have an elective surgical procedure informs the nurse that she wants "do-not-resuscitate" (DNR) status. Which of the following responses should the nurse make?

"Let's inform your doctor that you wish to have a DNR status." The provider must place the DNR prescription on the client's medical record for it to be effective. Without it, the staff might still choose to perform CPR, should the client have a cardiopulmonary arrest.

A nurse is reinforcing teaching about protecting client health information with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of confidentiality?

"The courts may require me to discuss confidential information." In some states the court may enact a court order requiring the nurse to discuss confidential client information. In most stats, the right to privacy of these records is extended in civil or criminal proceedings.

A nurse is receiving a providers prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? SATA

- Repeat the prescription back to the provider. The nurse should read the prescription back and have the provider confirm verbally that it is correct. -Question any part of the prescription that is unclear or inappropriate. This is essential for any prescription , verbal or written. - Transcribe the prescription into the client's medical record. This is the usual procedure after accepting a telephone prescription.

A nurse is caring for several clients on a medical-surgical unit. Which of the following client care situations requires the nurse to complete an incident report?

A client tells the nurse that his dentures are missing. The nurse should complete an incident report, also called a variance or occurrence report, for situations that vary from the established standard of care. A change of plan in the clients care might be necessary if the client has difficulty eating or speaking with our dentures. In addition, the hospital might be liable for replacing the missing dentures.

A nurse is participating in a staff discussion about disaster triage. The nurse should include which of the following clients as an example emergent (red tag) category?

A client who has a punctured femoral artery. The nurse should understand that the emergent (red tag) triage category is used for clients who have critical, Life-threatening injuries that can be managed with quick interventions.

A nurse us reinforcing teaching with a newly licensed nurse about ethical principles when providing client care. Which of the following situations should the nurse use as an example of negligence?

A nurse identifies the absence of Peripheral pulsation in a casted extremity in the early morning. The nurse reports the findings to the provider in the early afternoon. Negligence is conduct that does not show due care, It can be an act of omission, which id the failure to perform an act that a reasonable prudent person, under similar circumstances would do.

A charge nurse overhears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available. Which of the following actions by the charge nurse displays conflict resolution?

Address the situation as soon as possible. The charge nurse should address the situation as soon as possible to avoid escalation of the problem.

A nurse on a pediatric unit has received change-of shift report. Which of the following clients should the nurse plan to see first?

An infant who has pertussis and is receiving oxygen via nasal cannula. Using the airway, breathing, circulation (ABC) approach to prioritizing client care, this client should be seen first because the infant has a compromised airway and requires oxygen.

A nurse is caring for four clients on surgical unit. Which of the following task should the nurse delegate to the assistive personnel (AP)?

Assist a client to a chair who is 2 days postoperative following a cervical laminectomy. It is within the AP's scope of practice to transfer a stable client who is 2 days postoperative orthopedic surgery.

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

Close the curtains around the clients bed. Closing the curtains around the clients bed ensures privacy for the client should a visitor or another staff member open the door or enter the room.

A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

Contact Contact precautions are a type of transmission-based precaution for clients who have an infections by an organism that spreads either by direct or indirect contact.

A nurse is planning an in-service that encourages active member participation and feedback about decreasing nosocomial infections on the unit. Which of the following leadership styles does the nurse plan to use?

Democratic Democratic leadership encourages participation and cohesiveness in a group.

A nurse us caring for a client who is competent, refuses further treatment, and ask to sign out of the hospital against medical advice (AMA). The nurse notifies the charge nurse, who tells the nurse that the provider has recommended restraining the client, if necessary, to keep her from leaving the Hospital. The nurse refuses to implement the actions based on the knowledge that restraining this client would be committing which of the following torts?

False imprisonment False impriosonment is unlawful confinement against a clients will, The client has the right to refuse treatment and leave the Hospital

A nurse is assisting with revising a facility's emergency response plan for tornado disaster in the community. The nurse should plan to collaborate with which of the following agencies?

Federal Emergency Management Agency (FEMA) FEMA is the federal agency that manages and coordinates response to emergency situations.

A nurse is caring for a group of clients for the upcoming shift. Which of the following actions by the nurse indicates effective time management?

Gather supplies for a client scheduled for a procedure This is an example of effective time management because the nurse is being organized and prepared.

A nurse observes an assistive personnel (AP) entering the room of a client who is under contact precautions without earring personal protective equipment (PPE). Which of the following actions should the nurse take?

Give the AP the appropriate PPE. Due to the potential for the spread of infections organisms to other clients, the nurse should intervene by providing the appropriate PPE immediately.

A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of the SBAR?

History of the injury. The nurse should include the history of client's injury under the situation segment of SBAR, along with concurrent diagnosis.

A nurse is preparing to help with transferring a client who can partially assist to a gurney. Which of the following actions should the nurse take?

Lower the head of the bed. The nurse should lower the head of the bed as much as the client can tolerate. It is safe for the client to move laterally if he is supine.

A staff nurse suspects that a newly Licensed nurse is chemically impaired. Which of the following actions should the staff nurse take?

Notify the charge nurse of the situation. The staff nurse should validate her suspicion about the impaired coworker and then notify the charge nurse of the situation.