CC HESI pt2

Hospital administrators for a new facility are formulating a fire evacuation plan as part of the organizational disaster plan. Which is the best resource for the administrators to use during this process? a. The Life Safety Code® b. The Joint Commission c. The Centers for Medicare and Medicaid Services d. The Occupational Safety and Health Administration

a

The behavior of four nurses in different situations is given below. Which nurse exhibits a behavior that can be characterized as delegation according to Hersey's model? a. Nurse A b. Nurse B c. Nurse C d. Nurse D

b

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? a. Cognitive response b. Emotional response c. Perceptual response d. Physical response

a

Given below in the table are the conditions of four different clients. Which client's care should be delegated to unlicensed assistive personnel (UAP) to achieve effective outcomes in the care? a.Client A b. Client B c. Client C d. Client D

a

What should the community nurse teach about the risk of adolescent pregnancy? a. Risk for premature birth b. Risk for having a large baby c. Risk for chromosomal defects d. Risk for increased weight gain

a

The nurse is seeking a position as a clinical nurse leader in a major city hospital. What should the nurse prepare to do in order to secure this type of nursing role? Select all that apply. a. Pass the certification exam. b. Complete a master's degree in nursing. c. Learn how to prepare clinical pathways. d. Attend 30 hours of continuing education about the role. e. Pass the NCLEX-RN state board of nursing examination.

a, b

A healthcare provider prescribes epoetin subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first? a. Demonstrate the injection technique b. Assess the client's readiness to learn c. Explain how to perform sterile technique d. Encourage the client to contact a home healthcare agency

b

In order to minimize the likelihood for error during intravenous administration of antibiotics, the legal authority advised the delegatee to wear a colored vest that says, "Do not disturb! Medication administration in process." Which delegatee is appropriate to follow the advice of legal authority? a. Nursing aide b. Registered nurse c. Patient care associate d. Licensed vocational nurse

b

The healthcare team is caring for a client with neutropenia. Which task is delegated to unlicensed assistive personnel? a. Administering antibiotics b. Assisting with personal hygiene c. Monitoring for signs and symptoms of infection d. Teaching the client and caregivers about how to avoid infection

b

The registered nurse (RN) is getting ready to leave the client care unit for a lunch break. The RN asks the LPN to take care of a client during the lunch break. Which concept is emphasized in this situation? a. Leadership b. Delegation c. Supervision d. Assignment

b

Which aspects are considered when determining the willingness of a nursing assistant before delegating a task? Select all that apply. a. Ability b. Attitude c. Personality d. Confidence e. Commitment

b, d, e

When evaluating a task performed by a delegatee, the registered nurse finds that the delegatee fails to provide appropriate feedback. Which right of delegation is compromised in this situation? a. Right task b. Right person c. Right supervision d. Right communication

c

Which factor is known to hinder the ability of the triage nurse to adequately prioritize care? a. Lack of clinical experience b. Lack of baccalaureate degree c. Compassion fatigue d. A team-based approach to care

c

Which statement is true for attachment in the newborn? a. Attachment occurs for the first 28 days. b. Attachment begins in the first week of birth. c. Attachment is the overlapping of soft skull bones. d. Attachment is the interaction between parent and child.

d

The registered nurse is delegating tasks for nursing assistants caring for a client who requires more attention. Which element should be considered when selecting the suitable nursing assistant for delegation of a task? a. Time b. Safety c. Stability d. Critical thinking

d

What does the decision strategy of "offering" include in delegation? a. Allowing the delegator to examine the situation differently b. Demonstrating the specific task or behavior to improve client care c. Asking questions related to the problem or issue regarding client care d. Making a suggestion to facilitate the achievement of a desirable client care outcome

d

A client with postural hypotension requires nursing care. Which task can be safely delegated by the registered nurse to unlicensed nursing personnel (UNP)? Select all that apply. a. Mobilizing the client b. Assessing the pulse rate c. Assessing the blood pressure d. Managing foot care of the client e. Maintaining oral hygiene of the client

d, e

The legal authority wants a record of the tasks performed by the delegatees and asks the delegatees to maintain a record of completed tasks. Which task is marked by the licensed practical nurse (LPN)? a.Task A b. Task B c. Task C d. Task D

a

The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview? a. Asking about the client's current concerns b. Ensuring the interview follows a strict agenda c. Asking questions that promote short responses by the client d. Telling the client what he or she should expect from the visit

a

Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention? a. Treat the victim for shock. b. Start rescue breathing immediately. c. Apply surface pressure to the foot wound. d. Safely remove the victim from the immediate vicinity.

d

The registered nurse (RN) assigns a task to a licensed practical nurse (LPN) to take care of a client admitted with severe burns. Which tasks are being performed by the LPN in this situation? Select all that apply. a. Performing hygiene tasks b. Monitoring the heart rate c. Evaluating the medical reports d. Monitoring the blood pressure e. Administering the oral medication

b, d, e

During the immediate posttrauma period after injury to the frontal lobe of the brain, the nurse places a client in what position? a.Supine b. Side-lying c. Low-Fowler d. Trendelenburg

c

The delegatee is performing a task and in the process loses confidence in what he or she is doing. Which delegator's action may have contributed to the delegatee's loss of confidence? a. Intervening when the delegatee is performing the task b. Providing feedback about the work performed c. Communicating with the delegatee about the work being performed d. Stating that the task should be completed by a specified time

a

A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation? a. Begin active exercises. b. Make a referral to the physical therapist. c. Position the client to prevent contractures. d. Avoid moving the affected extremities unless necessary.

c

A healthcare team is caring for a client with diabetes insipidus. According to the functional model, which healthcare personnel would the nurse state is qualified to perform all hygienic tasks? a. Registered nurse b. Licensed practical nurse c. Licensed vocational nurse d. Unlicensed assistive personnel

d

Which client is most appropriate to be delegated to unlicensed assistive personnel (UAP) based on the given data? a. Client A b. Client B c. Client C d. Client D

d

Which groups may be activated by state and federal government authorities to assist during a flooding situation that results from a hurricane? Select all that apply. a. National Guard b. American Red Cross c. Medical Reserve Corps d. Public health departments e. Local emergency departments

a, b, c, d

A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit. When should the nurse take the neonate's mother to visit the infant? a. When the infant's condition has stabilized b. When the infant is out of immediate danger c. When the primary healthcare provider has provided written permission d. When the mother is well enough to be taken to the intensive care unit

d

What is the purpose of a community emergency response team (CERT)? a. Organizes untrained volunteers to help victims after a disaster b. Assists with staffing hospitals when victims arrive after a disaster c. Trains healthcare professionals in lifesaving skills to help victims of a disaster d. Reduces the need for professional services after a mass casualty incident

a

What should the nurse educator instruct a graduate nurse who is seeking employment? Select all that apply. a. Be a role model to the nursing staff b. Attend workshops and conferences c. Motivate other educators on the nursing unit d. Work on developing effective communication e. Approach institutions that provide mentoring

b, d, e

A client with foot ulcers is admitted to the hospital. The nurse manager should delegate the task of maintaining hygiene to which staff members to maximize efficient use of human resources? . Select all that apply. a. Registered nurse (RN) b. Patient care associate (PCA) c. Licensed practical nurse (LPN) d. Licensed vocational nurse (LVN) e. Unlicensed nursing practitioner (UNP)

b, e

The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? a. Ensuring the client's skin integrity b. Reviewing the preoperative instructions c. Administering general anesthetic to the client d. Placing the client in the correct position on the operating table

c

The registered nurse (RN) who delegates work to a newly hired licensed practical nurse (LPN) says, "Please tell me how you will go about performing this procedure, and I will share my expectations with you." Which behavior strategy of Hersey's model is being applied? a. Telling b. Selling c. Delegating d. Participating

d

Which component of delegation is considered a "two way process"? a. Authority b. Supervision c. Responsibility d. Accountability

c

Which are considered as nurse competencies within the synergy model of care delivery? Select all that apply. a. Collaboration b. Care planning c. Communication d. Clinical judgment e. Cultural competency

a, d, e

Which statement best explains the focus of a therapeutic milieu management? a. Management of a therapeutic milieu is a nursing responsibility. b. The nurse-patient relationship is dependent upon therapeutic milieu management. c. Milieu management creates an environment that supports the client's therapeutic care. d. Creating a therapeutic milieu requires a proactive approach on the part of the nurse.

c

Which factors does the registered nurse consider in the decision to delegate process? Select all that apply. a. Evaluation b. Nursing judgment c. Predictability of outcomes d. Pervasive functions of assessment e. Complexity of the task to be performed

c, e

Which client's healthcare requirements cannot be delegated? a. Client A b. Client B c. Client C d. Client D

c

Which of these clients is most appropriate for delegation to a cross-trained technician? a. Client A b. Client B c. Client C d. Client D

a

A green-tagged client arrives at the emergency department (ED) after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this client? a. Implementing decontamination measures b. Performing a head to toe physical examination c. Placing a special bracelet with a disaster number d. Taking a digital photo and placing it on the medical record

a

Which action should be the nurse's first priority for a client with major burns? a. Assessing airway patency b. Checking the client from head to toe c. Administering oxygen as needed d. Elevating the extremities if no fractures are noticed

a

Which facility has enabled rural hospitals to have increased access to specialist consultations? a. Medicare b. Medicaid c. Telemedicine d. Critical access hospital

c

A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client? a. Before the surgery b. During the convalescent phase c. On discharge from the hospital d. When it is time for a prosthesis

a

A client is admitted to the hospital with the diagnosis of acute salmonellosis. Which priority medication will the nurse prepare to administer? a. Opioids b. Antacids c. Electrolytes d. Antidiarrheals

c

Which members of the healthcare team are under dependent status when a task is delegated by the registered nurse (RN)? Select all that apply. a. Unit secretary b. Client attendant c. Registered nurse (RN) d. Primary healthcare provider e. Licensed vocational nurse (LVN)

b, e

The nurse manager is designated as a unit Chief during the formulation of a Hospital Incident Command System (HICS) for disaster preparedness. Which responsibility does the nurse manager assume in this role? a. Public information b. Medical command c. Safety and security d. Logistics and operation

d

The nursing team is involved in effective pain management. Which task would be performed by a registered nurse (RN) in this case? a. Performing hygiene tasks b. Taking and reporting vital signs c. Administering oral pain medications d. Developing a treatment plan for client's pain

d

A client has a prescription for an antibiotic in an intravenous piggyback (IVPB) of 50 mL of D5W to run for 30 minutes. The microdrip tubing has a drop factor of 60 gtt/mL. At what rate should the nurse set the IV infusion? Record your answer using a whole number. ______________ gtts/min

100

A delegator is providing feedback to four delegatees. Which feedback may undermine a long-term working relationship? a. A b. B c. C d. D

a

The nurse is assisting a client in labor. Which intervention should the nurse perform as soon as the newborn is delivered? a. Remove nasopharyngeal secretions b. Cover the newborn in a warm blanket c. Determine the newborn's Apgar score d. Place the newborn directly on the mother's abdomen

a

What happens when a registered nurse does not trust other individuals in the healthcare organization? Select all that apply. a. Altered client care b. Appropriate delegation c. Compromised healthcare d. Limited career opportunity e. Efficient time management

a, c, d

The nurse provides teaching to a client who has received a prescription for oral pancreatic enzymes, pancrelipase. The nurse evaluates that teaching is understood when the client identifies which time for medication scheduling? a. At bedtime b. With meals c. One hour before meals d. On arising each morning

b

A block nurse is caring for an elderly couple in the neighborhood. What kind of service does block nursing offer to the elderly clients? a. Diagnostics b. Health screening c. Running errands d. Communicable disease control

c

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? a. "I would, but my back hurts today." b. "Okay. It will be my good deed for the day." c. "Of course. I want to do whatever I can for you." d. "I would like to, but it is not in my job description."

c

A licensed practical nurse (LPN) was hired recently. Which strategy should be applied by the registered nurse (RN) to open lines of communication between them? a. Telling b. Selling c. Asking d. Offering

c

A nurse, while assessing different survivors of a tornado, assigns a red tag to a client. What could be the casualty condition of the client? a. No treatment, expected to die b. Treatment can be delayed, minor injuries c. Requires emergent treatment, threat to life d. Require immediate treatment, major injuries

c

A post-operative client is discharged to home. Which statement made by the nurse would be beneficial for the client's care in the home? a. "I will change the dressing every day." b. "I will recommend a physical therapy referral." c. "I will provide you with a homecare service referral." d. "I will not allow any family member to be present during dressing change."

c

In which positions should the nurse place a client who has just had a right pneumonectomy? a. Right or left side-lying b. High-Fowler or supine c. Supine or right side-lying d. Left side-lying or low-Fowler

c

One component of a hospital disaster plan would include a workplace violence protection plan. Which unit in the hospital would be the priority for implementation and evaluation of this plan? a. Medical unit b. Surgical unit c. Emergency department d. Maternity department

c

The nurse is managing a client who underwent cardiac bypass surgery. Which healthcare member can be safely delegated the task of monitoring electrocardiography? a. Nurse aide b. Certified technician c. Cross-trained technician d. Licensed vocational nurse (LVN)

c

What criteria should a nurse manager use to determine the feasibility of altering an emergency department triage process? (select all that apply) a. Research findings b. Remote capability c. Need for resources d. Readiness of others e. Evaluation of risk factors

c,d,e

A client arrives in the emergency department in cardiac arrest. Which priority action indicates that the nurse is acting as a leader? a. Trying to find the reason for the disease b. Asking for the history of any other diseases c. Waiting for the primary health care provider d. Resuscitating the client using clinical protocols

d

A client requiring long-term ventilator management is discharged from the health care facility. Which health care setting should this client be referred to? a. Home care b. Rehabilitation c. Assisted living d. Intermediate care

d

The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form? a. Nuclear family b. Extended family c. Single-parent family d. Skip-generation family

d

The nurse assists the healthcare provider in performing a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the healthcare provider to document? a. Homans b. Romberg c. Chvostek d. Queckenstedt

d

The nurse is developing a plan of care for a client who is using ritualistic behavior. Initially the nurse must understand what about the ritual? a. That it is under conscious control b. That it is used primarily for secondary gains c. That it helps the client focus on the inability to cope with reality d. That it helps the client control the level of anxiety the client is experiencing

d

A client requires emergency cardiac surgery. The leader nurse wants to make the client aware of the situation and wants the client to decide what should be done. Which ethical model does the leader nurse follow here? a. Autonomy model b. Paternalistic model c. Social justice model d. Patient-benefit model

a

What type of relationship between the nurse delegator and delegatee causes the nurse delegator to use the leadership behavior of telling? a. Limited b. Established c. New or developing d. Developing or ongoing

a

What are some challenges faced in the process of delegation? Select all that apply. a. Limited resources b. Large geographic area c. Time-saving considerations d. Vulnerable populations receiving care e. Provision of assistance with activities of daily living

a, b, d

Which nursing model includes a registered nurse (RN) paired with technical assistance? a. Team nursing model b. Co-primary nursing model c. Patient-focused care model d. Functional model of nursing

b

Which team member is most accountable when delegating a task to the healthcare team? a. Certified technician b. Registered nurse (RN) c. Licensed practical nurse (LPN) d. Unlicensed assistive personnel (UAP)

b

Before assigning a task, the registered nurse makes sure that the delegation process is appropriate to the situation. To which delegation right does this situation refer? a. Person b. Supervision c. Circumstance d. Communication

c

Which element creates an integrative process that fosters effective delegation decisions by the registered nurse? a. Ability b. Liability c. Stability d. Ethnicity

c

The nurse is providing care to several clients in the emergency department (ED). Which client is the priority when using the three-tiered triage system? a. A client with a simple fracture b. A client experiencing renal colic c. A client with severe abdominal pain d. A client with chest pain and diaphoresis

d

Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? a. Anthrax exposure b. Multicasualty incidents c. Mass casualty incidents (MCI) d. Weapons of mass destruction (WMD)

d

A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? a. It is unlikely that the client will regain the ability to walk. b. It prepares them for wearing braces. c. It assists them in overcoming orthostatic hypotension. d. They have the strength in the upper extremities for self-transfer.

a

A nurse is caring for a client with expressive aphasia. Which action should the nurse include when planning for the long-term care of this client? a. Begin helping the client to write. b. Encourage the client to acknowledge that this disability is permanent. c. Wait for communication to be initiated by the client even if it takes a long time. d. Assist family members to accept the fact that they cannot communicate verbally with the client.

a

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? a. Atrial fibrillation b. Forearm laceration c. Migraine headache d. Respiratory infection

a

The nurse is caring for a pregnant client with hypertension. Which client care tasks are most suitable to be delegated to the patient care associate (PCA)? a. Recording the vital signs b. Monitoring the blood pressure c. Administering intravenous fluids d. Administering antihypertensive medications

a

What are the elements integrated into delegacy? Select all that apply. a. Stability b. Leadership c. Clinical practice d. Critical thinking e. Communication

a, d

The registered nurse (RN) delegates a task to a licensed practical nurse (LPN). Which client task can be assigned to the LPN? a. Client A b. Client B c. Client C d. Client D

b

Which intervention does the nurse implement to develop a caring relationship with the client's family? a. Deciding healthcare options for the client b. Identifying the client's family members and their roles c. Declining to inform the client's family after performing a procedure d. Refraining from discussing the client's health with the family

b

The nurse interviews a client about a current health problem. The nurse then obtains and documents the client's temperature, blood pressure, and heart rate. Which step of the nursing process is involved in this situation? a. Planning b. Diagnosis c. Assessment d. Implementation

c

The registered nurse delegates a task to the unlicensed nursing personnel (UNP). Which client care is suitable for UNP? a. Client A b. Client B c. Client C d. Client D

c

What entity outlined the principles of delegation for registered nurses? a. Nurse Practice Act b. Multilevel nursing model c. American Nurses Association (ANA) d. National Council of State Boards of Nursing (NCSBN)

c

While teaching a nursing student about delegation, the registered nurse instructs the student to determine whether the delegation process is appropriate to the situation before delegating a task. Which right of delegation is the registered nurse referring to? a. Task b. Person c. Supervision d. Circumstance

d

A client is admitted to the hospital with severe burns. Which client response should the nurse anticipate during the acute phase of burn recovery? a. Unstable vital signs b. Decreased urinary output c. High serum potassium levels d. Reduced intravascular fluid volume

a

A client is to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is most important for the nurse to obtain? a. Infusion pump b. Tall intravenous (IV) pole c. Clamp taped at the bedside d. Infusion set delivering 60 drops/mL

a

A client underwent extraction of a tooth due to an underlying tumor one day ago. Which healthcare professional is appropriately involved in caring for the postoperative oral hygiene needs of this client? a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Licensed vocational nurse (LVN) d. Unlicensed nursing practitioner (UNP)

a

A client who had thoracic surgery is admitted to the postanesthesia care unit. What should the nurse do after the chest tube is attached to a disposable plastic water-seal drainage system? a. Ensure the security of the connections from the client to the drainage unit. b. Empty the drainage container and measure and record the amount once a day. c. Verify that there is vigorous bubbling in the wet suction control compartment. d. Check that the fluid level in the water-seal compartment increases with expiration.

a

A frantic parent calls stating their child has swallowed dish soap. What should the nurse advise? a. Call poison control. b. Induce vomiting immediately. c. Give syrup of ipecac, one tablespoon. d. Give activated charcoal, and expect black stools for 24 hours.

a

A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention? a. Monitor the vital signs every 15 minutes b. Maintain the client in the supine position c. Keep the client's lower extremities in extension d. Administer the prescribed oxygen at 4 L/min via nasal cannula

a

A nurse leader, along with the team, is caring for a client who is scheduled for colonoscopy. Which delegated task requires the leader's supervision? a. Assisting the client with an enema b. Assisting the client with bathing c. Assisting the client with feeding d. Assisting the client with ambulating

a

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare? a. Cool, moist towels b. Dry, sterile dressings c. Analgesic sunburn spray d. Vitamin A and D ointment

a

An older adult client who is confused and often does not recognize family members is admitted to a nursing home. The client appears slovenly, often soiling clothing with feces and urine. How can the nurse best manage this problem? a. Toileting the client every 2 hours b. Placing the client in orientation therapy c. Supervising the client's bathroom activities closely d. Explaining to the client how offensive the behavior is to others

a

As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints, because this may precipitate what? a. Pain b. Swelling c. Nodule formation d. Tophaceous deposits

a

Community members have received mailed notices asking them to come to different healthcare agencies within the community at the same time on the upcoming Saturday afternoon. What is the purpose of asking community members to perform this task? a. Test the emergency preparedness plan b. Determine if community members can read c. Measure the effectiveness of mailed communication d. Identify community members who do not work weekends

a

The RN caring for a postoperative hysterectomy client is delegating tasks to the licensed practical nurse (LPN). Which statement made by the RN indicates the principle of right communication of delegation? a. "Does the LPN understand when to report the vital signs?" b. "Can the LPN monitor blood pressure of the client effectively?" c. "Can the LPN provide effective feedback regarding the client's condition?" d. "Does the LPN have enough knowledge regarding administration of intravenous (IV) fluids to the client?"

a

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound? a. Red b. Black c. Green d. Yellow

a

The nurse is helping devise a training plan to familiarize health care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? a. Drills b. Tabletop exercises c. Access to the policy d. Computer simulations

a

The nurse uses evidence-based practice while providing nursing care to clients. What distinguishes research-based practice different from evidence-based practice? a. It uses knowledge based only on research studies. b. It is a problem-solving approach to clinical practice. c. It involves the conscientious use of current best practice. d. It involves clinical expertise and client preferences and values.

a

The registered nurse (RN) delegates the collection of respiratory rate data to a licensed practical nurse (LPN) for a client who is experiencing severe dehydration and whose condition is unstable. The LPN reports the data to the RN. The RN rechecks the data and finds that the report no longer reflects the patient's current condition. Which characteristic of communication has interfered with the delegation process? a. Information decay b. Information salience c. Confidence in abilities d. Synergy between team members

a

The registered nurse (RN) is the team leader for a group of clients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? a. Taking vital signs b. Providing wound care c. Conducting discharge teaching d. Administering oral medications

a

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? a. "Clients with decreased sensory perception of touch should be carefully monitored for infection." b. "Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts." c. "Clients with slower processing time should be provided with sufficient time to respond to questions or directions." d. "Clients with decreased coordination should be instructed to hold handrails when ambulating."

a

The registered nurse orders unlicensed nursing personnel (UNP) to check blood oxygen saturation levels every 6 hours and to report the results regularly. Which activity is the registered nurse performing in this situation? a. Active delegation b. Passive delegation c. Individual accountability d.Organizational accountability

a

What is the priority in preparing health care professionals for any type of disaster? a. Identification of hazards b. Cooperation with state authorities c. Collaboration with local authorities d. Implementation of federal mandates

a

When tasks are delegated by the registered nurse (RN) to the unlicensed nursing personnel (UNP), who can assume the responsibilities when the RN goes for a break? a. Charge nurse b. Chief nursing officer c. Healthcare provider d. Licensed practical nurse

a

Which action is appropriate for a nurse who is the triage officer after a high-speed commuter train derailment? a. Evaluating each client to determine priorities for treatment b. Being a liaison between the health care facility and the media c. Deciding the number, acuity, and resource needs for client care d. Assuming leadership for the implementation of the emergency plan

a

Which activity indicates improper follow-through on the part of the delegatee? a. Failure to report results b. Failure of effective communication c. Performing a task in the absence of a delegator d. Failure in following guidelines provided by a delegator

a

Which client care can be safely delegated to the unlicensed nursing personnel (UNP) to provide oral hygiene? a. Client A b. Client B c. Client C d. Client D

a

Which component of delegation is defined as the ability to perform duties in a specific role? a. Authority b. Supervision c. Responsibility d. Accountability

a

Which question does the registered nurse recognize as related to the right of circumstance when delegating? a. "Is the delegation appropriate to the situation?" b. "Is the task within the delegatee's scope of practice?" c. "Is the prospective delegate a willing and able employee?" d. "Is the delegator able to monitor and evaluate the client appropriately?"

a

Which statement best describes the navigator? a. A person who removes barriers to receiving health care b. A person who takes a client for a health care appointment c. A person who focuses on the long-term outcomes achieved by receiving needed care d. A person who ensures a specific plan of care is being followed to meet expected outcomes

a

Which statement made by the nurse indicates that the client interview is coming to a close? a. "I have just one more question for you." b. "I hope you are comfortable and not in pain." c. "I would like to spend some time to understand your concerns." d. "I assure you that information I gather now will be confidential."

a

The registered nurse (RN) has delegated a task to an unlicensed nursing personnel (UNP). After performing the task, the UNP reports to the RN for appraisal. Which statement by the UNP is related to individual accountability? Select all that apply. a. "I take full responsibility for the action performed." b. "I have ensured that the action has achieved the desired outcome." c. "I have ensured that there is a ventilator placed in every intensive care unit." d. "I have established systems for assessing and monitoring the tasks assigned." e. "I have evaluated whether the work environment is conducive to work or not."

a, b

What are the overall purposes of delegation? Select all that apply. a. To achieve nursing goals b. To improve client outcomes c. To develop critical judgment skills d. To understand the art of delegation e. To apply delegation decision in clinical nursing practice

a, b

Which factors should be assessed to determine the level of followers' readiness according to Hersey's model? Select all that apply. a. Ability b. Willingness c. Family history d. Work experience e. Educational qualifications

a, b

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. a. Fever b. Tachypnea c. Hypertension d. Abdominal rigidity e. Increased bowel sounds

a, b, d

A registered nurse delegates the task of administering oral antibiotics for a client with diabetes. Which statements are true in this scenario? Select all that apply. a. The registered nurse (RN) is accountable for the delegatee's work. b. The licensed practical nurse (LPN) should report to the RN once the task is completed. c. The unlicensed nursing practitioner (UNP) can also be delegated the task of administering oral antibiotics. d. The licensed practical nurse (LPN) can be held responsible for any failure in administration of oral medication. e. The licensed practical nurse (LPN) can change the medication dosage according to the client's physiological needs in the absence of the RN.

a, b, d

The registered nurse (RN) is delegating tasks to licensed practical nurses (LPNs) regarding client care. Which factors should be considered when delegating a task to the LPN? Select all that apply. a. Client's condition b. Complexity of the task c. Number of LPNs available d. Predictability of outcomes e. Relationship status between the delegatee and delegator

a, b, d

Which actions by the nurse help set the stage for a patient-centered interview during the first visit after admission to the healthcare facility? Select all that apply. a. Close the door after entering the room. b. Greet the client using his or her last name. c. Open the curtains to allow plenty of light in the room. d. Introduce oneself with a smile and explain the reason for the visit. e. Obtain an authorization from the client after the interview.

a, b, d

The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate? Select all that apply. a. Documenting vital signs b. Documenting urine output c. Assessing the laboratory findings d. Administering diuretic intravenously e. Repositioning the client every one or two hours

a, b, e

Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. a. Treatment b. Stabilization c. Evaluation of interventions d. Formulation of nursing diagnosis e. Decontamination for suspected contamination

a, b, e

A healthcare team is caring for a postsurgical client who underwent knee surgery. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply. a. Changing the dressing b. Ambulating the client c. Administration of oral analgesics d. Reinforcing leg exercise instructions e. Administering intravenous antibiotics

a, c, d

A client is hospitalized with dehydration and dysphagia. Which tasks are appropriate to delegate to a licensed practical nurse? Select all that apply. a. Administer medications b. Perform initial swallow screen c. Assist UAP with ambulating client d. Complete admission skin assessment e. Record vital signs on electronic health record

a, c, e

A nursing supervisor sends an unlicensed healthcare worker to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the health care worker? Select all that apply. a. Taking routine vital signs b. Applying a sterile dressing c. Answering clients' call lights d. Administering saline infusions e. Changing linens on an occupied bed f. Assessing client responses to ambulation

a, c, e

What must triage nurses employ when prioritizing care with any model? Select all that apply. a. A caring ethic b. Intensive care experience c. A systematic approach to care d. A baccalaureate degree in nursing e. Solid clinical decision-making skills

a, c, e

Which care activities would be involved in a correct delegation process? Select all that apply. a. Licensed practical nurse (LPN) cleans the client's body. b. Unlicensed assistive personnel (UAP) provides medication to the client. c. Unlicensed assistive personnel (UAP) assist the client with oral feedings. d. Licensed practical nurse(LPN) evaluates the client's temperature condition. e. Registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature.

a, c, e

A client is hospitalized with a brain injury and a skull fracture. The registered nurse is delegating tasks to the healthcare team. Which member of the healthcare team is suitable to provide client care? Select all that apply. a. Charge nurse b. Chief nursing officer c. Licensed practical nurse d. Newly hired registered nurse e. Unlicensed nursing professional

a, d

The nurse is assessing the level of readiness before delegating tasks to unlicensed assistive personnel (UAP). According to Hersey's model of situational leadership, what specific factors reflect the level of readiness? Select all that apply. a. Ability b. Honesty c. Reliability d. Willingness e. Conscientiousness

a, d

The nurse is trained to work as a member of a disaster preparedness team. Which activities should the nurse be prepared to perform if a disaster were to occur? Select all that apply. a. Triage b. Palliative care c. Home visits to newborns d. Decontamination procedures e. Evaluation of the disaster plan

a, d, e

Which conditions make a delegation more challenging for the registered nurses, delegatees, and clients? Select all that apply. a. Limited resources b. More staff availability c. More client care time d. Greater geographical area e. Vulnerable populations receiving care

a, d, e

The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan? Select all that apply. a. "We have to implement annual drills." b. "The plan must include an evacuation plan." c. "Nursing homes are not required to have a plan." d. "Our facility is held to the same standards as hospital facilities." e. "This is an important component to receive insurance payments for care."

a,b

Which nursing actions contribute to a healthcare facility's emergency preparedness and response prior to a natural disaster? (select all that apply) a. Participating in drills b. Evaluating outcomes c. Activating a telephone tree d. Performing a triage assessment e. Discharging clients who no longer require acute care

a,b

When using the AMPLE memory aid to conduct a health history during the emergency assessment, which questions will the nurse ask? (Select all that apply). a. "Do you smoke or drink?" b. "When was your last meal?" c. "Do you have any drug allergies?" d. "When was your last tetanus shot?" e. "How would you describe your current pain?"

a,b,c,d

A client is admitted to the emergency department following a motor vehicle accident. The client's wounds are extensive. Which healthcare team member is best suited to care for this client in the emergency ward? a. Charge nurse b. Registered nurse c. Licensed practical nurse d. Unlicensed nursing personnel

b

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? a. "I am unable to run a mile (1.6 kilometers) now." b. "I wake up at night short of breath." c. "My wife says I snore very loudly." d. "My shoes seem larger lately."

b

A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? a. "You will receive the anesthesia through a face mask." b. "You will receive medication through an intravenous (IV) catheter." c. "We will give you an oral medication about 1 hour before the procedure." d. "The medicine will be injected into your spine."

b

A client with chronic asthma is being cared for in the inpatient care unit. To assess the client on a regular basis would be delegated to which healthcare team member? a. Charge nurse b. Registered nurse c. Patient care associate d. Licensed practical nurse

b

A client with cirrhosis of the liver and ascites has been taking chlorothiazide, a thiazide diuretic. Why did the provider add spironolactone to the client's medication regimen? a. To stimulate sodium excretion b. To help prevent potassium loss c. To increase urine specific gravity d. To reduce arterial blood pressure

b

A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care? a. Nursing aide b. Registered nurse (RN) c. Patient care associate (PCA) d. Licensed vocational nurse (LVN)

b

A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, what should the nurse ask housekeeping personnel to do? a. Point this out to the client and remove the food. b. Report it to the nursing staff if it happens again. c. Disregard this because it is a common behavior in clients with anorexia. d. Keep a record of when this happens and report it to the nursing staff weekly.

b

A nurse manager delegates the task of phlebotomy to the members of a healthcare team who are caring for a client with diabetes. Which individual on the team can be delegated to perform the task of phlebotomy? a. Registered nurse b. Cross-trained technician c. Licensed vocational nurse d. Unlicensed assistive personnel

b

During a nursing team conference, a mental health worker suggests that a client with schizophrenia, paranoid type, be assigned to group therapy. What should the nurse manager explain about this type of therapy for this client? a. Individuals with this disorder respond well to small therapeutic groups. b. Therapeutic group work tends to be threatening to individuals who are suspicious. c. Compliance with unit rules and medication regimens increases as therapeutic group involvement increases. d. Involvement in small therapeutic groups may decrease the regression and dependency associated with institutionalization.

b

The nurse is making rounds and stops to check a client who has had a total hip arthroplasty. Which action by the unlicensed assistive personnel (UAP) ([continuing care assistant (CCA]) will cause the nurse to intervene? a. The client's heels are kept off the bed. b. The UAP (CCA) elevates the client's affected leg on a pillow. c. The UAP (CCA) uses a pillow to keep the client's legs abducted. d. The client uses a walker when ambulating with the UAP (CCA).

b

The primary healthcare provider prescribes a rectal suppository for a client with severe constipation. Which healthcare professional would be delegated the task of administering the suppository? a. Patient care associate b. Licensed practical nurse c. Unlicensed assistive personnel d. Unlicensed nursing personnel

b

The registered nurse (RN) is caring for a client who was admitted to the hospital due to severe diarrhea. The RN assigns the unlicensed assistive personnel (UAP) to check on the client hourly and perform hygiene care as needed. Which concept best explains this situation? a. Leadership b. Delegation c. Supervision d. Assignment

b

The registered nurse (RN) who was caring for a postsurgical client went out for a break. The RN assigns the work to a healthcare professional who is also an RN. Which is the correct statement regarding this situation? a. The situation describes delegation. b. The situation describes assignment. c. The second nurse holds accountability rather than responsibility for the client. d. The second nurse holds responsibility rather than accountability for the client.

b

The registered nurse assesses if an unlicensed assistive personnel (UAP) new to the unit is capable of carrying out a task. Which principle of delegation does this illustrate? a. Right task b. Right person c. Right circumstance d. Right communication

b

The registered nurse considers the qualification of the unlicensed nursing personnel (UNP) before delegating a task. Which right of delegation is followed by the nurse? a. Task b. Person c. Direction d. Supervision

b

The registered nurse delegates a task to the unlicensed assistive personnel (UAP). After the UAP starts the task, the registered nurse (RN) asks for feedback related to the task. Which right of delegation is the RN following? a. Task b. Supervision c. Circumstance d. Communication

b

The registered nurse oversees five unlicensed nursing personnel (UNP), and each UNP cares for five clients, so the registered nurse in effect has responsibility for five UNPs and 25 clients. What do these numbers of subordinate and clients indicate? a. Supervision b. Span of control c. Passive delegation d. Appropriate authority

b

What is the nurse's primary outcome goal when managing the care of a client diagnosed with generalized anxiety disorder (GAD)? a. Creating an anxiety-free environment for the client b. Assisting the client with the development of healthy, adaptive coping mechanisms c. Identifying the triggers that produce anxiety in the client d. Providing reinforcement that the client's anxiety issues can be eliminated

b

What nursing action will most help a client obtain maximum benefits after postural drainage? a. Administer oxygen as needed. b. Encourage coughing deeply. c. Place the client in a sitting position. d. Encourage the client to rest for a half hour.

b

Which behavior of the delegator with respect to the work delegated to a delegatee is characterized as "selling" according to the Hershey's Model? a. Guiding or directing b. Explaining or persuading c. Observing or monitoring d. Encouraging or problem solving

b

Which behavior of the nurse leader is characterized as delegating according to the Hersey's model? a. Guiding or directing b. Observing or monitoring c. Explaining or persuading d. Encouraging or problem solving

b

Which certification course may be an elective for a nurse qualified to care for clients in a disaster-related emergency situation? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS)

b

Which health care professional is accountable for establishing systems to assess and communicate competency requirements related to delegation? a. Registered nurses b. Chief nursing officers c. Licensed practical nurses d. Unlicensed nursing personnel

b

Which nursing intervention is employed to encourage the client to fully reveal the nature of their health problem? a. The nurse takes down notes while the client is talking. b. The nurse leans forward attentively during the discussion. c. The nurse refrains from pausing enough after each question. d. The nurse asks questions that can be answered as "yes" or "no."

b

Which statement of the nurse is true regarding Hersey's Situational Leadership Model? a. The situational leadership model cannot be applied to real work-related situations. b. The situational leadership model provides a solid foundation for delegation decisions. c. The situational leadership model does not relate to the behavior of the delegatee during delegation. d. The situational leadership model contends that managers should not behave differently on different occasions.

b

Who is most accountable for an initial assessment and the ongoing evaluation of client care? a. Client b. Registered nurse c. Licensed practical nurse d. Unlicensed nursing personnel

b

The registered nurse (RN) is caring for a client who underwent ileostomy. Which activity performed by the nurse indicates following the principle of right circumstance of delegation? Select all that apply. a. Assessing the willingness of the delegatee b. Assessing the equipment to determine vital signs c. Providing supervision of the delegatee during the task d. Teaching institutional policies about caring for a client with ileostomy e. Communicating with the delegatee about care management of the client

b, c

Which individuals will the emergency department (ED) charge nurse collaborate with during an actual disaster to organize nursing and ancillary services to meet client needs? Select all that apply. a. Paramedics b. Triage officer c. Trauma program manager d. Medical command physician e. Unlicensed assistive personnel

b, c, d

The nurse manager is delegating tasks to the healthcare team to care for a client who underwent brain surgery. Which individuals on the team share accountability during delegation? Select all that apply. a. Attendant b. Nurse manager c. Certified technician d. Healthcare provider e. Unlicensed nursing personnel (UNP)

b, d

The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Select all that apply. a. Assessing the vital signs b. Performing all hygiene tasks c. Administering oral medications d. Helping the client in changing clothes e. Administering intravenous medications

b, d

A client with hypoglycemia is admitted to the hospital. Which duties can the registered nurse (RN) safely delegate to the licensed practical nurse (LPN)? . Select all that apply. a. Intravenous fluid intervention b. Administering oral medications c. Monitoring the fluctuating vitals d. Analyzing the case history of the client e. Administering intramuscular medication

b, e

A healthcare team is caring for a 68-year-old client with diabetes insipidus. Which task is most suitable to be delegated to licensed practical nurse (LPN) to provide effective client care? Select all that apply. a. Emptying the urinary drainage bag b. Monitoring urine output c. Feeding the client with food d. Administration of intravenous fluids e. Administering oral rehydration medication

b, e

The nurse delegates the tasks of caring for a postpartum client. During assessment, the nurse observes an infection in the client caused by lack of hygiene. Which member of the health care team is most likely responsible for the client's condition? Select all that apply. a. Physician b. Registered nurse c. Licensed practical nurse d. Licensed vocational nurse e. Unlicensed assistive personnel

b, e

The registered nurse (RN) is planning to provide feedback to the licensed practical nurse(LPN). Which questions asked by the RN help in eliciting the LPN's work quality? Select all that apply. a. "Are you feeling well today?" b. "How did the patient respond?" c. "Has the task been completed?" d. "Are you willing to perform the task?" e. "What changes were observed in the client?"

b, e

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others? a. Insert a urinary catheter. b. Initiate droplet precautions. c. Move the client to a private room. d. Use a high-efficiency particulate air (HEPA) respirator during care.

c

A client sustains a back injury after falling 20 feet (6 m). In which position should the nurse place the client? a. Lateral position with a pillow between the knees b. Any position that reduces pain and is comfortable c. Supine position while not allowing the spine to flex d. Sitting position with a pillow placed in the small of the back

c

A client who had surgery for a laryngectomy is returned to the surgical unit from the postanesthesia care unit. In which position is it most appropriate for the nurse to place the client at this time? a. Prone with the head turned to one side b. Supine with the knees flexed at 10 degrees c. Lateral with the head slightly elevated and flexed d. Supine with the head in a hyperextended position

c

A client who sustained a leg fracture is prescribed intramuscular analgesic medication. Which healthcare professional can be safely delegated this task? a. Registered nurse (RN) b. Patient care associate (PCA) c. Licensed practical nurse (LPN) d. Unlicensed nursing practitioner (UNP)

c

A nurse is caring for a client 8 hours after surgery. The client's portable wound drainage device is half full of drainage. After emptying the drainage collection chamber, how will the nurse create negative pressure in the system? a. Attaching the device to a wall suction unit b. Milking the tubing toward the suction device c. Compressing the device while closing the air plug d. Keeping the device in a position lower than the site of insertion

c

A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? a. Fruits b. Grains c. Red meat d. Vegetable oils

c

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? a. Discharge in am b. Blood glucose monitoring ac and bedtime c. Erythromycin 250 mg TIW d. Dalteparin 5000 international units Sub-Q BID

c

A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action? a. Authority b. Autonomy c. Accountability d. Responsibility

c

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the healthcare provider's writing. Who should the nurse ask for clarification of this prescription? a. Nurse practitioner b. House healthcare provider who is on call c. Healthcare provider who wrote the prescription d. Nurse manager familiar with the healthcare provider's writing

c

A registered nurse is teaching a student nurse about the functions and utilization of trauma centers. Which statement of the student nurse indicates effective learning? a. "Clients requiring advanced life support should be sent to a level II trauma center." b. "Most injured clients requiring urgent treatment should be sent to a level I trauma center." c. "Clients requiring stabilization with major injuries should be sent to a level III trauma center." d. "Clients requiring full continuum of trauma services should be sent to a level IV trauma center."

c

A staff member is planning to start a new job but is worried about the impact it might have on future growth opportunities. The nurse leader is helping the staff member understand all the implications. Which ethical principle is the nurse manager as a leader following? a. Justice b. Veracity c. Paternalism d. Non-maleficence

c

An administrator for a community hospital notes that actions to help with emergency room visits caused by adverse weather events have not been successful over the last few months. What should the administrator consider implementing to address ongoing issues? a. Interprofessional team b. Monthly data collection processes c. Permanent quality improvement (QI) team d. Evidence-based practice research guidelines

c

During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important? a. The client should understand what will be discussed. b. The client will know that the nurse is trying to be helpful. c. The client needs to know what to expect from the relationship. d. The client will be able to be prepared for termination of the relationship.

c

The charge nurse is preparing for the arrival of clients to the emergency department (ED) after a mass casualty incident (MCI). The hospital has an automatic tracking system that is implemented during MCIs. Which decision should the nurse use the system for during this MCI? a. To determine the number of on-call staff needed b. To determine the specific plan to be implemented c. To determine how many casualties of each acuity level can be safety accepted d. To determine how many clients can be safety discharged to allow for new admissions

c

The client with methicillin-resistant staphylococcus aureus (MRSA) is admitted to the medical unit. Which of the following tasks should be performed by the registered nurse? a. Feeding b. Administrating oral medication c. Initiating intravenous (IV) antibiotic therapy d. Changing the dressing of a postoperative wound

c

The healthcare provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond? a. "It prevents excessive blood clotting." b. "It suppresses irritability in the ventricles." c. "It improves oxygen supply to heart tissue." d. "The inotropic action increases the force of contraction of the heart."

c

The licensed practical nurse (LPN) has been asked to monitor the blood pressure of a client with hypertension. The LPN reports to the registered nurse (RN) that the blood pressure monitor is malfunctioning. Which component of the duty is the LPN practicing? a. Authority b. Supervision c. Responsibility d. Accountability

c

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? a. Meet the clients' family. b. Read the clients' medical reports. c. Participate in the bedside rounds. d. Visit the clients and introduce self.

c

The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care? a. Careful monitoring for crepitus b. Bed rest with range-of-motion exercises c. Coughing and deep breathing every hour d. Covering the chest tube site with a sterile dressing

c

The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process? a. Removing the cervical spine collar b. Monitoring for autonomic dysreflexia c. Implementing the logrolling technique d. Administering the prescribed pain medication

c

The registered nurse (RN) administers intravenous fluids to a client who was in a motorcycle accident. Which assessments made by the nurse would be appropriate based on the principle of right task of delegation? a. Environmental conditions b. Resources required for drug administration c. Institutional policies of drug administration d. Client's condition prior to drug administration

c

The registered nurse (RN) delegates a task to a licensed practical nurse (LPN) to take care of the client who underwent a tracheostomy. Which task should be performed by the LPN in this situation? a. Developing a plan to avoid aspiration b. Assessing the client's condition after tracheostomy c. Providing tracheostomy care using sterile techniques d. Teaching a client and caregiver about home tracheostomy care

c

The registered nurse (RN) is caring for a client with severe diarrhea. Which task of the client care plan can be safely delegated to the unlicensed assistive personnel (UAP) by the registered nurse? a. Administration of oral antidiarrheal b. Administration of intravenous antibiotics c. Administration of oral replacement fluids d. Administration of intravenous antiemetics

c

The registered nurse assigns a task to a licensed practical nurse (LPN) to check the blood pressure and temperature of a client. Which factor is transferred to the LPN for the performance of the task? a. Liability b. Authority c. Responsibility d. Accountability

c

The registered nurse delegates the task of feeding a 90-year-old client suffering from dysphagia to the unlicensed assistive personnel (UAP) who has previously performed this task. The client died of choking and aspiration after being fed by the UAP. Which right of delegation was violated for this client? a. Task b. Person c. Circumstance d. Communication

c

What is the status of the primary healthcare provider as a member of the healthcare team that is in the span of control of a registered nurse (RN)? a. Devoid of legal authority b. Devoid of delegation authority c. Answerable to the nurse manager d. Answerable to the registered nurse

c

What makes a crisis access hospital (CAH) different from an intensive care unit (ICU)? a. It offers 24-hour emergency care. b. It offers health care to acutely ill people. c. It provides temporary care for 96 hours or less. d. It provides the most expensive health care delivery.

c

When caring for a client with venous insufficiency, the nurse would implement which nursing measure? a. Apply abdominal girdle as needed. b. Remove compression stockings for client ambulation. c. Elevate the client's legs above heart level. d. Keep the upper extremities elevated.

c

Which action, if performed by the nurse, is inappropriate while caring for different clients after a disaster? a. Teaching and supervising volunteers b. Providing on-site first aid and emergency care c. Evacuating injured and uninjured people from a danger area d. Teaching clients about procedures that are needed for safety

c

Which activity performed by the licensed practical nurse (LPN) would be appropriate while caring for a client based on the principle of right task of delegation? a. Willing to perform the task b. Providing feedback to the delegator c. Performing the task based on institutional policies d. Following appropriate supervision while performing the task

c

Which activity performed by the registered nurse (RN) indicates effective supervision of the delegatee? a. Assigning the task to the delegatee b. Taking responsibility of the delegated task c. Guiding the delegatee while he or she is performing the task d. Understanding the nurse practice of the state

c

Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? a. Local emergency management system b. State emergency management system c. Federal emergency management agency d. Hospital-level emergency management system

c

While delegating a specific task, the registered nurse says to the delegatee, "It is important that you measure the client's blood pressure every 15 minutes." What does this situation indicate? a. The delegatee requires little guidance. b. The delegator is providing explanation. c. The delegator is providing more guidance. d. The delegator and delegatee are creating mutual expectations.

c

Why does a nurse manager assign a resource person in a healthcare organization? a. To delegate tasks b. To supervise actions c. To serve as a mentor d. To reassign duties to workers

c

A client hospitalized for heart failure is receiving digoxin and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? a. Monitoring vital signs and encouraging a vigorous aerobic exercise program b. Providing written material on the adverse effects of the medication c. Contacting Social Services for a home health nursing consultation d. Teaching the client how to count the pulse

d

A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family? a. "Please do not worry, everything will be alright." b. "I am sorry; I do not have any information about the client." c. "You will have to wait for the primary healthcare provider." d. "Please wait; I will update you as soon as I have any information."

d

A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide therapy via tablets has been prescribed. The nurse anticipates that the dosage will be changed frequently during the first week of therapy. While the dosage is being adjusted, what action does the nurse perform? a. Administer the medication after meals. b. Administer the medication on an empty stomach. c. Evaluate the client's psychological responses between medication doses. d. Evaluate the client's muscle strength every hour after the medication is given.

d

A client is brought to the emergency department following ingestion of pesticides. The primary health care provider orders gastric suction. Which task can be delegated to the unlicensed assistive personnel (UAP) in this situation? a. Monitoring the vital signs b. Evaluating the client response c. Gastric suctioning through vented tube d. Emptying and measuring the gastric drainage

d

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? a. Localized seizures b. Skin desquamation c. Hyperactive reflexes d. Ascending weakness

d

A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide, and long-term steroid therapy has been initiated. What is especially important for the nurse to ensure? a. The client increases sodium intake. b. Protective isolation is established. c. Total daily fluid intake is decreased. d. The client is monitored for an exacerbation of symptoms.

d

A healthcare provider prescribes famotidine and magnesium hydroxide/aluminum hydroxide antacid for a client with a peptic ulcer. The nurse should teach the client to take the antacid at what time? a. Only at bedtime, when famotidine is not taken b. Only if famotidine is ineffective c. At the same time as famotidine, with a full glass of water d. One hour before or 2 hours after famotidine

d

A healthcare team is caring for a client with dental pain. Which task is most suitable to be delegated to unlicensed assistive personnel (UAP) to provide effective client care? a. Administering analgesics b. Administering intravenous antibiotics c. Administering nerve block anesthesia d. Administering mouth wash for oral hygiene

d

A newborn has just begun to breast-feed for the first time. Although the neonate has latched on to the mother's nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse best intervene at this time? a. Tell the client to use the other breast and continue breast-feeding b. Delay the feeding to allow more time for the infant to recover from the birthing process c. Contact the lactation consultant to help the client learn a more successful breast-feeding technique d. Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula

d

A nurse delegator assigns work to a delegatee who has the ability and willingness to do the work but the relationship between the delegator and delegatee is relatively new. How is the delegator's behavior described according to Hersey's Model? a. Selling b. Telling c. Delegating d. Participating

d

A nurse is preparing a client for discharge from the emergency department. Which client statement provides evidence that the client understands the instructions for the prescribed high-dose ampicillin? a. "I should take this medication with meals." b. "I can stop taking this medication when I feel better." c. "I will miss eating my yogurt while taking this medication." d. "I must increase my intake of fluids while taking this medication."

d

A nurse manager promotes a staff nurse to assistant manager of the medical unit as the staff nurse had expressed interest in taking on more responsibilities. Which type of ethical principle is exhibited by the nurse manager by this activity? a. Fidelity b. Autonomy c. Paternalism d. Beneficence

d

After delegating a task to the unlicensed assistive personnel (UAP), the registered nurse (RN) provides clear and concise directions to the delegate, to whom she assigned the task. Which right of delegation is the RN following? a. Task b. Supervision c. Circumstance d. Communication

d

An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? a. Confirm the client's relationship first. b. Ask the client's primary healthcare provider. c. Inform the nurse manager and show the records. d. Explain that medical health records are confidential.

d

The nurse is assisting a client out of bed. Which is the priority nursing action? a. Monitoring the client's blood pressure b. Assessing the client's level of consciousness c. Ensuring the call bell is within the client's reach d. Assisting the client from a supine to an upright position

d

The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? a. Oxygen therapy b. Cardiac monitoring c. Nutrition supplements d. Venous thromboembolism (VTE) prevention

d

The nurse is providing interventions to give support services for delivery of care. According to the Nursing Intervention Classification (NIC) taxonomy, which domain does this care belong to? a. Behavioral b. Community c. Physiological d. Health system

d

The nurse is providing postoperative care for a college student who has undergone a knee arthroscopy for a tendon repair. The client is scheduled to be discharged in a few hours and plans to return to the college dormitory and spend the weekend there before returning to class in 2 days. What is most important for the nurse to include in the client's discharge plans? a. Arrange for a taxi to return the client to the dormitory. b. Instruct the client to restrict activities for at least several days. c. Suggest the client spend the weekend in a motel near the hospital. d. Ask the client who is available in the dormitory to provide assistance.

d

The nurse is teaching breathing exercises to a client who underwent surgery. Which member of the healthcare team is most suitable for reinforcement of teaching in the client? a. Certified technician b. Case manager c. Cross-trained technician d. Licensed vocational nurse (LVN)

d

The registered nurse (RN) delegated a task to a licensed practical nurse (LPN). The LPN completed the task effectively. Which statement made by the RN is appropriate feedback? a. "Nice job." b. "Well done." c. "Your performance was good." d. "You performed that procedure safely and professionally."

d

The registered nurse is caring for a client admitted to the hospital with chronic obstructive pulmonary disease. Which assessment by the registered nurse before delegating would help to determine the principle of "right person"? a. "Is the environment conducive for completing the task safely?" b. "Does the licensed practical nurse (LPN) know about polices of the institution?" c. "Can the nursing assistive personnel (NAP) evaluate the client's' condition appropriately?" d. "Does the nursing assistive personnel (NAP) have the knowledge and expertise to perform the task?"

d

The registered nurse is teaching a newly hired nurse about active delegation. Which statement made by the newly hired nurse indicates the need for further teaching? a. "I will evaluate the client's pain status." b. "I will assess the client's laboratory findings." c. "I will instruct the unlicensed assistive personnel (UAP) to wash the client." d. "I will instruct the licensed vocational nurse (LVN) to administer intravenous (IV) medications."

d

When does a delegator identify that the delegatee is less able to perform in a given situation? a. When the delegatee is upset b. When the delegatee is bored c. When the delegatee is anxious d. When the delegatee is knowledge deficient

d

Which action by the nurse constitutes constructive feedback for the delegatee? a. Providing verbal attacks on feedback b. Providing feedback to individual delegatee c. Providing nonspecific feedback about the behavior d. Providing open feedback about specific strategies for change

d

Which activity performed by the registered nurse (RN) indicates following the "participating" leadership style in Hersey's model? a. Delegating the work to the delegatee b. Evaluating the ability of the delegatee c. Providing little guidance to the delegatee d. Establishing mutual expectations with the delegatee

d

Which client situation may benefit from the nurse issuing a contract regarding the plan of care? a. An infant's parents prior to hospital discharge b. A preschool-age child requiring immunizations c. A school-age child who is active in afterschool sports d. An adolescent who is seeking information regarding birth control

d

Which individual is categorized as one who would be considered as "dependent status"? a. Unit secretary b. Nurse manager c. Registered nurse (RN) d. Licensed practical nurse (LPN)

d

Which is the priority nursing action to decrease the risk for a client developing a hospital-acquired infection? a. Using droplet precautions b. Using contact precautions c. Using airborne precautions d. Using standard precautions

d

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? a. Face tent b. Venturi mask c. Nasal cannula d. Nonrebreather mask

d

Which response by the nurse who is earning certification as a member of the Disaster Management Assistance Team (DMAT) indicates accurate understanding regarding the responsibilities of the team? a. "I will be the facility incident commander." b. "I will be a member of an all registered nurse team in the field." c. "I will be covered by the Good Samaritan law as a member of this team" d. "I will be expected to work a three day shift with the supplies we are given."

d

A client is admitted to the hospital for cranial surgery. What does the nurse include in the preoperative plan of care? a. Helping the client put on a wig before the client's visitors arrive b. Obtaining the client's consent for shaving the head c. Braiding the client's hair to keep it contained during surgery d. Instructing the client that with all cranial surgeries, the head is shaved after anesthesia has been administered

b

While caring for a client with diabetes, the registered nurse delegates the task of administering oral medications to the licensed practitioner nurse (LPN), but the LPN is reluctant to take the assignment. What should be the most appropriate response of the registered nurse in this situation? a. Evaluate the reason for the behavior. b. Engage more actively in the delegated task. c. Require the delegatee to complete the task. d. Report the LPN's reluctance to higher authorities.

a

Which healthcare settings are appropriate for delegating care according to the functional model of nursing? Select all that apply. a. Hospice units b. Emergency units c. Inpatient facilities d. Ambulatory clinics e. Acute care agencies

b, d

What should a nurse manager as a leader do to provide a non-threatening and positive environment to the group members? Select all that apply. a. Ask indirect and close-ended questions b. Encourage group members to actively participate c. Create an environment conducive to solving problems d. Protect the members and their suggestions from attack e. Encourage the attempts of members to monopolize the discussion

b, c, d

Which members of the health care team have dependent status under the registered nurse? Select all that apply. a. Unit secretary b. Certified nursing aide c. Licensed practical nurse d. Licensed vocational nurse e. Unlicensed nursing personnel

b, c, d, e

Which statement best describes a fundamental aspect of the clinical nurse leader (CNL)? a. Schedules staff to cover work shifts b. Evaluates care for evidence-based approaches c. Serve as a liaison between team leaders and other care providers d. Meets with unlicensed assistive personnel (UAP) to review tasks

b

A client who weighs 176 pounds (80 kg) is being immunosuppressed by daily maintenance doses of cyclosporine to prevent organ transplant rejection. The dose prescribed is 8 mg/kg each day. How many milligrams should the nurse plan to administer each day? Record your answer using a whole number. __________________ mg

640

Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? A. A motor vehicle accident involving 5 cars. B. A tornado destroying 50 homes and businesses. C. An act of terrorism injuring and killing hundreds of people. D. A hurricane causing flooding and displacing thousands of people.

A

A client is admitted to the hospital with severe backache and chest discomfort. After reviewing the client's condition, there is a need for 24-hour client care by the registered nurse (RN). Which healthcare professional is responsible for assigning the task to a registered nurse when 24-hour client care is needed? a. Nurse manager b. Nursing supervisor c. Chief nursing officer d. Primary healthcare provider

a

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? a. Determine the client's emotional state. b. Give prescribed drugs to promote bronchiolar dilation. c. Provide education about the impact of a family history. d. Encourage the client to use an incentive spirometer routinely.

b

A client has been receiving lithium for the past 2 weeks for the treatment of bipolar disorder, manic phase. What will the nurse include in the teaching plan for this client? a. A diuretic is necessary for anyone taking lithium. b. Lithium must be taken for the rest of the client's life. c. The blood level of lithium must be checked every month. d. A low-sodium diet must be followed while lithium is being taken.

c

A client scheduled for surgery has a history of methicillin-resistant Staphylococcus aureus (MRSA) since developing an infection in a surgical site 9 months ago. The site is healed, and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present? a. Notify the infection control officer. b. Inform the operating room of the MRSA. c. Obtain an order to culture the client's blood. d. Call the surgeon for an infectious disease consultation.

c

Which healthcare team member is considered the priority person to insert an indwelling urinary catheter for a client who underwent a hysterectomy? a. Registered nurse b. Patient care associate c. Licensed practical nurse d. Unlicensed assistive personnel

c

Which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care? a. Avoiding manipulation of the client's limbs b. Asking a family member about any client drug allergies c. Cutting fabric that is stuck to the client's skin with scissors d. Auscultating heart and lung sounds through the client's clothing

c

Which nursing action should be included in the plan of care for a client who has a permanent fixed (asynchronous) pacemaker inserted? a. Instruct the client that it is better to sleep on two pillows b. Encourage the client to reduce activity from former levels c. Teach the client to keep daily accurate records of the pulse d. Inform the client that the pacemaker functions when the heart rate drops below a preset rate

c

Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a. Providing oxygen b. Encouraging carbohydrates c. Administering fluid replacement d. Teaching facts about dietary principles

c

Which right does the question, "Do staffing ratios demand the use of high-level delegation strategies?" indicate? a. The right task b. The right person c. The right supervision d. The right circumstance

d

Which strategy should be implemented by the registered nurse (RN) to achieve desirable client outcomes? a. Doing b. Asking c. Talking d. Offering

d

While assigning a task, the registered nurse finds that one of the delegatees is not competent to hold the current position. Which strategy does the nurse follow for managing this issue during delegation? a. Attacking the delegate verbally b. Doing the task himself or herself c. Adjusting the quality of client care d. Lowering the expectations temporarily

d

While caring for a client with arthritis, the delegator gave the task of administering medication intramuscularly to the client to another healthcare team member. Which healthcare team member is most appropriate to perform the task? a. Certified technician b. Registered nurse (RN) c. Patient care associate (PCA) d. Licensed practical nurse (LPN)

d

Which task can be delegated to the licensed vocational nurse (LVN)? Select all that apply. a. Analyzing vital signs b. Maintaining oral hygiene c. Administering intravenous drugs d. Administering oral hypoglycemic agents e. Administering intramuscular medications

d, e

What principal components are associated with a nurse's time management skill? Select all that apply. a. Autonomy b. Goal setting c. Priority setting d. Interruption control e. Right communication

b, c, d

A client is admitted with a diagnosis of chronic adrenal insufficiency. Which roommate should be avoided when assigning a room for this client? a. A young adult client with pneumonia b. An adolescent client with a fractured leg c. An older adult client who had a brain attack d. A middle-aged client who has cholecystitis

a

A registered nurse (RN) delegates a task to a licensed practical nurse (LPN). What should the RN do when the LPN executes the task improperly? a. Provide constructive feedback. b. Engage in a verbal attack on the delegate. c. Express satisfaction with the LPN's execution of the task. d. Ignore the task for now but stop considering the LPN for further delegation.

a

In a health care setting, there are a limited number of unlicensed nursing personnel. Who would take up the responsibility of delegation in place of the registered nurse? a. Charge nurse b. Chief nursing officer c. Patient care associate d. Licensed practical nurse

a

The healthcare provider prescribes nitroglycerin ointment for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? a. "I may experience a headache." b. "Confusion is a common adverse effect." c. "A slow pulse rate in an expected side effect." d. "Increased blood pressure readings may occur initially."

a

What is the status of the unit secretary as a member of the healthcare team, which is in the span of control of a registered nurse (RN)? a. Devoid of legal authority b. Answerable to the nurse manager c. Answerable to the registered nurse d. Devoid of performing non-medical tasks

a

Which element of the healthcare system is the registered nurse (RN) practicing when the delegator shares accountability with the RN? a. Delegation b. Leadership c. Supervision d. Assignment

a

Which health care provider would best help a homeless client receive needed medication for a communicable disease? a. Navigator b. Case manager c. Primary nurse d. Unlicensed assistive personnel

a

Which healthcare professional would the nurse know is held accountable for the tasks performed by the patient care associate (PCA)? a. Registered nurse (RN) b. Licensed vocational nurse (LVN) c. Unlicensed assistive personnel (UAP) d. Unlicensed nursing practitioner (UNP)

a

Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? a. Covering the nose b. Protecting the eyes c. Decontaminating the skin d. Administering prophylactic antibiotics

a

While caring for a client with a permanent disability, the delegator delegated a task to the unlicensed assistive personnel (UAP). What type of care is provided to this client? a. Long-term care b. Restorative care c. First-access care d. Rehabilitative care

a

Who functions as a liaison between team leaders and other healthcare providers? a. Charge nurse b. Registered nurse c. Nursing manager d. Chief nursing officer

a

Who is accountable for the ongoing evaluation of a client's care? a. Registered nurse (RN) b. Chief nursing officer (CNO) c. Licensed practical nurse (LPN) d. Unlicensed nursing personnel (UNP)

a

Which are disadvantages to the functional system of care delivery? Select all that apply. a. Poor communication b. Fragmentation of care c. Efficiency with specific tasks d. Fixed number of registered nurses e. Changes in client status go unnoticed

a, b, e

Which statement is correct regarding delegation? Select all that apply. a. It involves transfer of authority. b. The delegator retains accountability for the outcome. c. The delegatee retains accountability for the outcome. d. It is the transfer of both responsibility and accountability. e. Principles of delegation outline what nurses need to know about the task.

a, b, e

A client who underwent a nephrectomy develops pneumonia after being cared for by a registered nurse (RN) with some duties delegated to a cross-trained technician. Which individuals on the healthcare team may be responsible for the complication? Select all that apply. a. Registered nurse b. Patient care associate c. Cross-trained technician d. Licensed vocational nurse e. Unlicensed assistive personnel

a, c

The nurse manager is planning to assign an unlicensed healthcare worker to care for clients. What care can be delegated on a medical-surgical unit to an unlicensed healthcare worker? Select all that apply. a. Performing a bed bath for a client on bed rest b. Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) c Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered d. Assisting a client who has patient-controlled analgesia (PCA) to the bathroom e. Assessing the wound integrity of a client recovering from an abdominal laparotomy

a, d

The registered nurse (RN) is caring for an older client who has been admitted to the hospital. The RN allocates several tasks to the unlicensed nursing personnel (UNP). In order to evaluate the understanding of the UNP, the RN asks the UNP to describe which tasks have been allocated. Which responses given by the UNP indicate effective understanding of the tasks? Select all that apply. a. "I must assist the client with oral care." b. "I must assess the client's health status." c. "I must administer intravenous drug in accordance with the schedule." d. "I must give a sponge bath to the client every morning." e. "I must record the blood pressure of the client at regular intervals."

a, d, e

A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client? a. Sims b. Semi-Fowler c. Trendelenburg d. Dorsal recumbent

b

A client with emotional problems is being discharged from a psychiatric unit. What should the nurse encourage the client to do? a. Go back to regular activities. b. Enroll in an aftercare program. c. Call the unit whenever she is upset. d. Find a group that has similar problems.

b

A group of individuals is working as a team in a rehabilitation program. Which nursing team member has the responsibility of acting as the team leader? a. Unit secretary b. Registered nurse c. Licensed practical nurse d. Unlicensed nursing personnel

b

A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returning to the situation. What is the best response by the nurse manager? a. "She must not have the financial resources to leave her husband." b. "Most women try to leave about six times before they are successful." c. "There's nothing the staff can do; people are free to choose their own lives." d. "These women should be told how stupid they are to stay in that kind of situation."

b

A primary healthcare provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do? a. Advise the client to get more rest. b. Schedule the client for an appointment. c. Instruct the client to skip one dose daily. d. Tell the client to increase the medication.

b

The registered nurse (RN) is caring for a client who underwent surgery for a pituitary tumor. Which task can be delegated to unlicensed nursing personnel (UNP)? a. Teaching the client b. Monitoring vital signs c. Assessing laboratory reports d. Evaluating the status of the client

b

The registered nurse (RN) is teaching a novice RN about delegating tasks to licensed practical nurses (LPN) and unlicensed assistive personnel (UAP). Which statement made by the novice RN indicates a need for further teaching? a. "I will delegate the task of reinforcing client teaching to the LPN." b. "I will delegate the task of assisting the client with bathing to the LPN." c. "I will delegate the task of recording vital signs of the client to the UAP." d. "I will delegate the task of administering intramuscular injections to the LPN."

b

Which characteristic indicates that nursing is a profession? a. The nurse is trained to perform specific tasks. b. The nurse is required to follow a code of ethics. c. The nurse is required to have a collection of specific skills. d. The nurse has limited autonomy in decision making and practice.

b

Which factor is known to threaten the nurse's ability to triage and prioritize client care accurately? a. A caring ethic b. A biased approach to care c. The shift that is being worked d. The specific number of years of job experience

b

When should the nurse consider family members as the primary source of information? Select all that apply. a. The client is an elderly adult. b. The client is an infant or child. c. The client is brought in as an emergency. d. The client is critically ill and disoriented. e. The client visits the outpatient department.

b, c, d

A registered nurse is teaching a group of student nurses about concepts of triage in a mass casualty incident. Which statement of the student nurse indicates effective learning? a. "I will issue a black tag to class II, urgent clients." b. "I will issue a yellow tag to class I, emergent clients." c. "I will issue a green tag to class III, nonurgent clients." d. "I will issue a red tag to class IV, expected-to-die clients."

c

During a follow-up visit three weeks after a laryngectomy, a client exhibits concern that the laryngectomy tube may become dislodged. What should the nurse teach the client to do if the tube becomes dislodged? a. Reinsert another tube immediately. b. Notify the healthcare provider at once. c. Keep calm because this is no immediate emergency. d. Quickly take action to prevent the tracheal stoma from closing.

c

Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position? a. Provides the greatest comfort b. Restores circulating blood volume c. Helps stop bleeding if any should occur d. Reduces the fluid trapped in the biliary ducts

c

The nurse is assessing a young couple planning to start a family. What should the nurse tell the couple about the change that they will have to encounter in their family life-cycle? a. Develop intimate peer relationships b. Maintain own functions and interests c. Realign relationships with extended family d. Refocus on midlife material and career issues

c

The plan of care for the client was to lose 7 lbs (3.2 kg) by the end of the month. The client only lost 3 lbs (1.4 kg). How should the nurse respond? a. Assume that the client has been cheating on the diet. b. Increase the goal for next month to keep the client on track. c. Reevaluate the plan of care for appropriateness. d. Discontinue the plan of care because it did not work.

c

The registered nurse (RN) is caring for a pregnant client with malnutrition due to morning sickness. Which task can be safely performed by the licensed practical nurse (LPN) in this condition? a. Assessing hemoglobin levels b. Evaluating nutritional status c. Administering oral antiemetics d. Administering intravenous fluids

c

To reduce a fracture of the hip, a client is placed in Buck traction before surgery. Because the client keeps slipping down in bed, increased countertraction is prescribed. What should the nurse do to increase countertraction? a. Add more weight to the traction. b. Elevate the head of the client's bed. c. Use a slight Trendelenburg position. d. Apply a chest restraint around the client.

c

Which parameter monitoring should be the nurse's priority while caring for a client with hypothyroidism? a. Pulse rate b. Blood pressure c. Respiratory rate d. Body temperature

c

Which personnel should the nurse state are responsible for deciding the number, acuity, and resources needed for clients during a disaster? a. Triage officer b. Community relations officer c. Medical command physician d. Hospital incident commander

c

Which phase in the disaster management continuum does the nurse understand as including the attempt to limit a disaster's impact on human health and community function? a. Recovery b. Response c. Mitigation d. Preparedness

c

A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? a. Advising the client to join a support group immediately after discharge b. Assuring the family that staff members will take care of the client's needs c. Reminding the client to keep medical follow-up appointments after discharge d. Conducting a multidisciplinary staff conference early during the client's hospitalization

d

A client with a fractured head of the right femur and osteoporosis is placed in Buck extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? a. Remove the weights from the traction every 2 hours to promote comfort. b. Turn the client from side to side every 2 hours to prevent pressure on the coccyx. c. Raise the knee gatch on the bed every 2 hours to limit the shearing force of traction. d. Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion.

d

A nurse manager transfers the task of caring for a client who has undergone appendectomy to a registered nurse (RN). Which element of the healthcare system is the RN practicing? a. Delegation b. Leadership c. Supervision d. Assignment

d

A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse manager asks the registered nurse, "Are the equipment and resources available for the LPN to complete the task?" Which right of delegation is the nurse manager preserving? a. Right task b. Right direction c. Right supervision d. Right circumstance

d

Which among the Five Rights of Delegation is the cornerstone of delegation? a. "Right person" b. "Right supervision" c. "Right circumstance" d. "Right communication and direction"

d

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? a. Choking b. Redness c. Gagging d. Cyanosis

d

Which client's care is least likely to be delegated to unlicensed nursing personnel (UNP)? a. Client A b. Client B c. Client C d. Client D

d

While caring for a client, the registered nurse (RN) needs the assistance of a licensed practical nurse (LPN). The RN feels that the LPN requires supervision as the LPN has previously only worked in a physician's office. Which action by the RN would help diminish any negative feelings the LPN might have about being supervised? a. Initiating a conversation about the limited skills of the LPN b. Appreciating the performance of the LPN when providing feedback c. Explaining the policies and procedures of the organization d. Initiating a conversation about the new role and functions of the LPN

d