INTEGRATION PRACTICE QUESTIONS FOR FINAL # 1 IDOLIS

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse? "You may carry your grandchild to the room." "You can push the baby to the room in a wheeled bassinet." "Have the mother call and I will take the baby to the room." "If you show me your photo identification, you can take the infant."

"Have the mother call and I will take the baby to the room." Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting an infant to remain in the mother's room.

A nurse is preparing a presentation about hospice care services. Which of the following statements should the nurse plan to make during the presentation? "During hospice care services, the caregiver receives a break from caring for the client for personal time." "Hospice care services keep the family updated on the client's condition." "Hospice care services are initiated when the client has less than 2 years to live." "During hospice care services, the client can receive their IV chemotherapy medications."

"Hospice care services keep the family updated on the client's condition." Hospice care services provide comfort and support for the client and their family. The hospice team is responsible for keeping the family updated on the client's condition.

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification? "I can change who I designate as my health care proxy at any time." "If I become incapacitated, end-of-life choices will be made by my proxy." "I have to choose a family member as my health proxy." "The health care proxy does not go into effect until I am incapable of making decisions."

"I have to choose a family member as my health proxy." The client should choose someone he trusts and knows about his wishes for day-to-day and end-of-life care. It can be a family member, but it does not have to be a family member.

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? "I will have to be admitted to a long-term care facility in order to receive hospice care." "I should expect the hospice team to help me manage my dyspnea." "Hospice care services are available to patients who are terminally ill regardless of their life expectancy." "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."

"I should expect the hospice team to help me manage my dyspnea." Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness.

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide? "You know it's not appropriate for you to ask me that." "It's my responsibility to remind you that we have to respect our clients' privacy." "It's a minor injury. I'm sure you'll see her back in the neighborhood soon." "Oh, what lovely flowers. She will enjoy these."

"It's my responsibility to remind you that we have to respect our clients' privacy." This therapeutic response provides clarification to the messenger that the hospital staff cannot disclose information about clients.

A nurse is discussing psychiatric advance directives (PAD) with a client. Which of the following statements should the nurse make? "PAD can include preferences for treatment, such as medications and preferred providers." "PAD is not a legally binding document, like a living will." "PAD is used by the majority of clients who have a mental illness." "PAD does not allow a client to choose someone to make health care decisions on their behalf if they are unable to do so."

"PAD can include preferences for treatment, such as medications and preferred providers." PAD is a legal document similar to other medical advance directives and allows a client to specify their treatment preferences if they become unable to do so for themselves.

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching? "The legal requirement for client confidentiality ceases if the client is deceased." "Staff members are required to divulge information to attorneys if they call for information." "Health care workers are not required to answer a court's requests for information about a client's disclosure." "Providers are required to warn individuals if the client threatens harm."

"Providers are required to warn individuals if the client threatens harm." Health care professionals have a duty to warn and protect third party individuals who may be in danger due to the client's threats of harm.

A nurse is caring for a client whose family member requests to view the client's medical record. Which of the following responses should the nurse make? "I will ask the nursing supervisor to obtain the medical records for you." "The health care provider will share this information with you." "The ethics committee will need to approve this request for you." "The client must provide permission to share the records with you."

"The client must provide permission to share the records with you." Client information is shared only with individuals involved directly in the client's care. The client must provide permission for the family to access protected health information.

A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "The courts might require me to discuss confidential information." "I am required to provide confidential information to insurance companies." "If questioned during a police investigation, I am required to divulge confidential information." "I am legally allowed to discuss confidential information with the client's former therapist."

"The courts might require me to discuss confidential information." In some states, the court may enact a court order requiring the nurse to discuss confidential client information.

A nurse is caring for a client who has bipolar disorder and asks the nurse, "Who should get a copy of my advance directives?" Which of the following statements should the nurse make? "Giving you legal advice about advance directives is outside my scope of practice." "Advance directives are not needed for individuals who have a mental illness." "You should provide a copy to your providers, family members, and lawyer." "You only need to provide a copy to your family."

"You should provide a copy to your providers, family members, and lawyer." The client should provide a copy of their advance directives to their providers, family members, and lawyer. It is important that any potential decision makers, health care providers, and legal representatives be made aware of the client's wishes.

A nurse manager is preparing to discuss breach of confidentiality with their staff. Which of the following statements should the nurse manager plan to make? "Your employer can terminate your employment if there is a breach in confidentiality." "The State Board of Nursing can reprimand you for a breach of client confidentiality." "Your institution can receive monetary fines for a breach in confidentiality." "The civil penalties for breach of confidentiality can include imprisonment." "A breach in confidentiality is considered an act of professional negligence."

"Your employer can terminate your employment if there is a breach in confidentiality" is correct. Nurses are legally obligated to maintain client confidentiality and privacy. When there is a violation or breach in confidentiality, there is a potential consequence. If a nurse breaches a client's confidentiality, their employer can suspend or terminate their employment. "The State Board of Nursing can reprimand you for a breach of client confidentiality" is correct. Nurses are legally obligated to maintain client confidentiality and privacy. When there is a violation or breach in confidentiality, there is a potential consequence. The State Board of Nursing is obligated to protect the public. Therefore, they can reprimand a nurse or revoke licensure depending on the breach of confidentiality. "Your institution can receive monetary fines for a breach in confidentiality" is correct. Nurses are legally obligated to maintain client confidentiality and privacy. When there is a violation or breach in confidentiality, there is a potential consequence. The institution in which the nurse is employed can receive criminal penalties, monetary fines, and Medicare reimbursement revocation. "The civil penalties for breach of confidentiality can include imprisonment" is correct. Nurses are legally obligated to maintain client confidentiality and privacy. When there is a violation or breach in confidentiality, there is a potential consequence. The civil penalties for breach of confidentiality includes monetary fines and imprisonment.

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client? 208 212 214 216

208 A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.

A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients? A child who is experiencing sickle cell crisis A child who has streptococcal pharyngitis A child who has a head injury A child who has a new diagnosis of type 1 diabetes mellitus

A child who has a new diagnosis of type 1 diabetes mellitus The nurse should place these clients together. It is appropriate because the child who has diabetes requires monitoring and teaching and the child who is postoperative from an appendectomy requires frequent assessments and interventions.

A nurse is reviewing room assignments for a group of clients. Which of the following clients should the nurse assign to a room that is near the nurses' station? (Select all that apply.) A client who has engaged in cutting behaviors A client who was admitted for threatening to kill themselves A client who has frequent anger outbursts A client who is easily distracted during art therapy A client who cannot sit still at breakfast

A client who has engaged in cutting behaviors is correct. The nurse should assign a client who has engaged in cutting behaviors to a room that is near the nurses' station to allow for close observation of the client. A client who was admitted for threatening to kill themselves is correct. A client who was admitted for threatening to kill themselves should be assigned a room near the nurses' station to allow for close observation of the client. A client who has frequent anger outbursts is correct. A client who has frequent anger outbursts should be assigned a room that is near the nurses' station to allow for close observation of the client.

A nurse is caring for a group of clients. Which of the following clients is eligible for hospice care? A client who has a new diagnosis of COPD and requires supplemental oxygen. A client who has stage IV breast cancer and is expected to live 3 months. A client who has terminal lung cancer and has discontinued all treatment. A client who has end-stage kidney disease and has stopped dialysis. A client who has type 1 diabetes mellitus and is on an insulin pump.

A client who has stage IV breast cancer and is expected to live 3 months is correct. This client is terminal and is eligible for hospice care to provide comfort and support to the client and their family. A client who has terminal lung cancer and has discontinued all treatment is correct. This client is terminal and is eligible for hospice care to provide comfort and support to the client and their family. A client who has end-stage kidney disease and has stopped dialysis is correct. This client is terminal and is eligible for hospice care to provide comfort and support to the client and their family.

A nurse is caring for a group of clients. Which of the following clients is eligible for hospice care? (Select all that apply.) A client who has a new diagnosis of COPD and requires supplemental oxygen. A client who has stage IV breast cancer and is expected to live 3 months. A client who has terminal lung cancer and has discontinued all treatment. A client who has end-stage kidney disease and has stopped dialysis. A client who has type 1 diabetes mellitus and is on an insulin pump.

A client who has stage IV breast cancer and is expected to live 3 months is correct. This client is terminal and is eligible for hospice care to provide comfort and support to the client and their family. A client who has terminal lung cancer and has discontinued all treatment is correct. This client is terminal and is eligible for hospice care to provide comfort and support to the client and their family. A client who has end-stage kidney disease and has stopped dialysis is correct. This client is terminal and is eligible for hospice care to provide comfort and support to the client and their family.

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station? A client who sustained a head injury and is having periods of confusion A client who reports a severe migraine headache A client who has a suspected diagnosis of tuberculosis (TB) A client who has a history of atrial fibrillation and is on continuous ECG monitoring.

A client who sustained a head injury and is having periods of confusion A client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs.

A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first? A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode A client who was admitted for chest pain and is reporting a new onset of indigestion A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400 A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800

A client who was admitted for chest pain and is reporting a new onset of indigestion A client who has a history of chest pain and is reporting a new onset of indigestion is unstable; therefore, this client is the highest priority.

A nurse on a pediatric unit is caring for four clients. The nurse should recommend an interdisciplinary client care conference for which of the following clients? A client who was diagnosed with cystic fibrosis and has a distended abdomen. A client who is 10 hr postoperative from an appendectomy. A client who is 6 hr postoperative from a tonsillectomy. A client who was diagnosed with acute diarrhea from the Norovirus.

A client who was diagnosed with cystic fibrosis and has a distended abdomen. Cystic fibrosis is a genetic disease that requires the management of respiratory, gastrointestinal, and endocrine problems. A multidisciplinary approach is needed to promote quality of life for this client.

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? A negative-pressure isolation room A semi-private room with a client who has pediculosis capitis A positive-pressure isolation room A private room

A private room The nurse should place a client who has a communicable condition, such as scabies, in a private room to reduce the risk of exposure and possible transmission to other clients. If necessary, the nurse can use a semi-private room with a client who has the same condition.

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client? A private room in a quiet location on the unit A semi-private room with a roommate who has a similar diagnosis A private room close to the nursing station A seclusion room until the client's activity level becomes more subdued.

A private room in a quiet location on the unit A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.

A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client? A semi-private room across from the day room. A private room in a quiet location on the unit. A private room across from the exercise room. A semi-private room across from the snack area.

A private room in a quiet location on the unit. A private room decreases stimuli for the client and does not subject another client to his overactive behavior.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A room with air exhaust directly to the outdoor environment A room with another nonsurgical client A room in the ICU A room that is within view of the nurses' station

A room with air exhaust directly to the outdoor environment A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A public health nurse is involved in community-engaged research related to reasons for low immunization rates of children in county public schools. Which of the following situations does the nurse recognize as a potential ethical issue involving recruitment of research participants or confidentiality of information? A primary care clinic offers use of their conference room for data collection. The owner of a local store donates supplies for data collection. The leader of the data collection team delivers supplies to the team members at their homes. A school principal offers to provide immunization records of students.

A school principal offers to provide immunization records of students. The nurse should identify that the principal offering to provide immunization records of students is a potential ethical issue involving confidentiality of information.

A nurse is caring for a client who has end-stage liver disease and states, "I am aware of the dangers of continuing to drink, but I am choosing not to stop." Which of the following actions should the nurse take to act as a client advocate? Inform the client that they are better off without medical care if they continue to drink. Report the client's refusal to comply to the charge nurse and end the discussion. Ask the client's family to remove alcohol from the client's home. Accept the client's decision and offer to be a resource if the client changes their mind.

Accept the client's decision and offer to be a resource if the client changes their mind. The nurse is advocating for the client by ensuring that they have the right to make decisions about their own health.

A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first? A school-age child who has diabetes mellitus and requires blood glucose monitoring An infant who has pertussis and is receiving oxygen via nasal cannula An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions A toddler who has both arms in casts and needs to be fed his breakfast

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

A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? A client who has previously undergone a procedure that is to be performed for a second time A client who has been educated on treatment options and chooses alternative treatments A client who makes an informed decision not to participate in chemotherapy treatment An older adult client who has no family and is uncertain about moving to assisted living

An older adult client who has no family and is uncertain about moving to assisted living The nurse acts as an advocate by ensuring the client has correct information to make an appropriate decision in selecting needed services. This is an example of a client benefitting most from the nurse acting as an advocate.

A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first? Notify hospital security. Approach the man and ask why he is making copies. Inform the nursing supervisor. Report the observation to the nurse caring for that client.

Approach the man and ask why he is making copies. The first action the nurse should take using the nursing process is to assess the situation to determine whether this man is authorized to be in possession of the client's medical record to protect the client's confidentiality. Making copies from a client's medical record is allowed under specific circumstances. It is important to act in a timely fashion to protect the client's medical information. The nurse should approach the individual in a nonthreatening way to inquire about the copies being made.

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation? Assigning two assistive personnel (AP) to ambulate all clients Assigning a new graduate nurse to perform a wet-to-dry dressing change Assigning the most efficient AP to perform glucometer monitoring for each client Assigning the most competent RN to perform a central line dressing change

Assigning the most efficient AP to perform glucometer monitoring for each client Asking the most efficient AP to perform glucometer testing based on her efficiency in performing this task is an example of overdelegation. This can result in the AP becoming overworked and tired, thus decreasing productivity.

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.) Bathe a client who had an amputation 2 days ago. Assist a client to ambulate using a gait belt. Review a low-sodium diet for a client who has hypertension. Explain oral hygiene to a client receiving chemotherapy. Feed a client who had a stroke 3 months ago.

Bathe a client who had an amputation 2 days ago is correct. Bathing a stable client postoperatively is a task the nurse may delegate to an AP because the task is routine and is safe and predictable for a client who is stable. Assist a client to ambulate using a gait belt is correct. Assisting a client to ambulate using a gait belt is a task the nurse may delegate to an AP because the task is routine and does not require much scientific knowledge. Feed a client who had a stroke 3 months ago is correct. Feeding a client who had a stroke 3 months ago is a task the nurse may delegate to an AP because the task is routine and is safe and predictable for a client who is stable.

A charge nurse is teaching a newly licensed nurse the importance of client confidentiality. Which of the following professional standards should the charge nurse refer to in the teaching? Principles of Nursing Practice Code of Ethics for Nurses Nursing Scope and Standards of Practice American Nurses Association Position Statements

Code of Ethics for Nurses The charge nurse should include the professional standard of the Code of for Nurses which is part of the American Nurses Association in the teaching. This standard provides behaviors and practices nurses should follow to provide ethical care to clients which can include confidentiality and protecting clients' rights.

A nurse is discussing a client's needs at an interdisciplinary team conference. The client had a stroke and requires inpatient rehabilitation incorporated into their plan of care. Which of the nursing competencies is the nurse demonstrating? Advocate Nurse manager Collaborator Case manager

Collaborator The nurse is demonstrating the nursing competency of a collaborator. By speaking with other members of the interdisciplinary team, such as the provider, case manager, physical therapist, and pharmacist, each member contributes their knowledge to provide optimal and quality care that is needed for the client.

A nurse overhears two assistive personnel (APs) disagreeing about client care assignments. Which of the following actions by the nurse demonstrates conflict resolution? Report the APs to the charge nurse. Confront the APs to discuss their argument. Tell the APs they are acting immature. Allow the APs to resolve their issues.

Confront the APs to discuss their argument. The nurse demonstrates conflict resolution by confronting the APs to discuss their argument. Conflict management is a method to settle disagreements peacefully and respectfully, through compromise and accommodation to each other's needs, sharing goals, and avoiding competition with the other individual.

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation? "Delegation provides appropriate resources for the client." "Delegation permits a designated individual to meet a goal on your behalf." "Delegation promotes discharge teaching activities for clients." "Delegation decreases health care costs."

Delegation permits a designated individual to meet a goal on your behalf." Delegation is defined as directing the performance of others to accomplish goals of the nurse and the facility.

A traveling nurse is taking a temporary assignment out of state. Which of the following information should the nurse identify is the purpose of the Nursing Licensure Compact (NLC)? Grants the nurse permission to practice in more than one state Requires the nurse to reapply for a new license Requires continuing education from previous state to maintain licensure Provides the nurse with a new license in the new state

Grants the nurse permission to practice in more than one state The nurse should identify the NLC grants the nurse permission to practice in more than one state that is a compact state without having to obtain another license for that state. There are 34 states within the United States that are multistate licensed.

A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse should explain that nurses may share a client's protected health information with which of the following groups? The client's immediate family members Clergy affiliated with the facility The facility's administrators Health care team members caring for the client

Health care team members caring for the client To coordinate safe and effective care delivery, the nurse may share details of a client's health status and treatment plan with others who are responsible for delivering client care. The Health Insurance Portability and Accountability Act (HIPAA) allows sharing of information necessary for treating clients.

A nurse is teaching a newly licensed nurse about hospice care. Which of the following information should the nurse include? The goal of hospice care is to prolong life. Hospice care cannot be discontinued once it is initiated. Hospice care is restricted to clients who are terminally ill. Hospice care is limited to clients who are in a health care facility.

Hospice care is restricted to clients who are terminally ill. Hospice care is restricted to clients who are terminally ill, such as those who have a life expectancy of less than 6 months.

A nurse is answering questions at a school meeting about government entities that regulate health care. The nurse should include that which of the following organizations advocates for the delivery of culturally competent health care? Center for Medicare and Medicaid Services (CMS) Indian Health Service (IHS) Administration on Aging (AoA) Administration for Children and Families (ACF)

Indian Health Service (IHS) The IHS's mission is to promote the health of American Indians and Alaska Natives and to advocate for culturally competent care.

A nurse working on a surgical unit receives a phone call from a client's neighbor who requests a postoperative update of the client's condition. Which of the following actions by the nurse is appropriate? Provide the neighbor with a brief statement about the client's condition. Inform the neighbor that you do not have information about the client. Suggest that the neighbor call the client's health care provider for the information. Transfer the neighbor's call to the telephone in the client's hospital room.

Inform the neighbor that you do not have information about the client. Informing the neighbor that you do not have any information about the client upholds the client's rights under the federal legislation known as the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of personal health information. The nurse should avoid making a statement verifies that the neighbor is a client in the facility.

At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN? Providing postmortem care for a client Measuring a client's I&O Obtaining a client's weight Inserting a nasogastric tube for a client

Inserting a nasogastric tube for a client This is an appropriate task to assign to the LPN. It is not appropriate to assign this task to the AP.

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? Transpersonal Intrapersonal Interpersonal Public

Interpersonal Interpersonal communication is face-to-face interaction with another person. It results in an exchange of ideas, problem solving, expression of feelings, decision-making and personal growth.

A public health nurse is speaking with a client about why it is important to be an advocate for the environment. Which of the following reasons should the nurse identify as the primary purpose for environmental advocacy? It can help ensure Earth's resources are available in the future. It ensures there is an equal balance between the natural and built environment. It aligns with the Sustainable Development Goals. It puts more pressure on politicians to adjust budgets.

It can help ensure Earth's resources are available in the future. Nurses should serve as role models in their community, leading efforts to protect the Earth's precious resources.

A community health nurse who has failed to complete proper documentation for a client is now expected to undergo retraining and practice under the supervision of another nurse. Which of the following elements of Nursing's Social Contract does this address? Progress and development Knowledge, skill, and competence Caring service Ethical practice

Knowledge, skill, and competence The nurse is demonstrating the element of knowledge, skill, and competence of Nursing's Social Contract. Failing to complete proper documentation requires standards of practice to address the incompetency and ensure this action will not be repeated.

A community health nurse is part of a team that plans to propose a policy that improves access to primary care. Which of the following is the first step in becoming competent as a policy making advocate? Locating the correct level and jurisdiction where an idea can be introduced Calling legislators Posting about the issue on social media Developing a proposal for the policy

Locating the correct level and jurisdiction where an idea can be introduced When generating solutions, the nurse should determine that the initial step as a policy making advocate is locating the correct level and jurisdiction.

A charge nurse is observing the actions of an assistive personnel (AP). Which of the following actions by the AP is appropriate? Logging off the computer after entering a client's intake and output totals Providing her password to a new nurse in orientation so that the new nurse can enter her client's vital signs Posting the client's medical diagnosis on a message board in the client's room Discarding her nursing activity work sheet in a waste basket at the nurse's station at the end of the shift

Logging off the computer after entering a client's intake and output totals The AP should log off the computer after using it to ensure that unauthorized individuals do not have access to confidential information.

A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Perform wound irrigation for a client. Evaluate pain relief for a client following the administration of a pain medication. Measure and record intake and output for a client. Teach a client about low-sodium foods.

Measure and record intake and output for a client. The AP can measure and record intake and output (I&O) for a client. It is the nurse's responsibility to review the recorded results and respond as necessary.

A nurse case manager for an employer-sponsored health insurance plan is implementing a program to control costs associated with hypertension. Which interventions should the nurse implement to help with cost control on a tertiary prevention level? Medication adherence program Blood pressure screening events for all employees Education about the risk factors for hypertension Promoting meditation for all employees Walking program for employees who have hypertension

Medication adherence program is correct. Tertiary prevention aims to limit further complications for a client who has a condition. The implementation of a medication adherence program will decrease health care costs. The nurse should implement a medication adherence program to help with cost control on a tertiary prevention level. Walking program for employees who have hypertension is correct. A walking program for employees who have hypertension will assist with controlling costs on a tertiary level. Since they have the condition, walking would prevent further complications.

A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the following legal torts applies to this situation? Negligence Libel Battery Slander

Negligence The nurse's conduct displays negligence, which is providing client care below the standard of care and placing the clients at risk for harm.

A charge nurse has access to the facility's electronic client records. It is appropriate for the charge nurse to share her personal password with whom? The nurse manager No one A nursing student who is completing a preceptorship on the unit The unit clerk

No one Computer passwords cannot be shared with others for any reason. Any facility employee authorized to have access to the database on a computer will have a personal password.

A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client? Occupational therapist Psychiatric social worker Recreational therapist Psychiatric clinical nurse specialist

Occupational therapist An occupational therapist's primary focus is client's achieving independence with ADLs.

A nurse is working with an interdisciplinary disaster committee to develop a community-wide emergency response plan in the event of a nonbiological or chemical incident. The nurse should include which of the following agencies to be notified immediately after calling 911? Office of Emergency Management (OEM) Federal Emergency Management Agency (FEMA) American Red Cross (ARC) U.S. Department of Homeland Security (DHS)

Office of Emergency Management (OEM) The nurse should include OEM in the community communication plan to be contacted following the call to the emergency communication center (911). This agency is responsible for determining if additional resources to the initial first responders are needed.

A nurse preparing to collaborate with interdisciplinary team about the child's care. Medical History Child presented to provider's office 3 days ago. Guardians were concerned that the child had decreased energy for the past 2 weeks, low grade fevers that they treated with acetaminophen. The guardians also noticed a red rash to the child's chest and right upper extremity Child was admitted to pediatric oncology unit and has been diagnosed with Acute Lymphoblastic Leukemia (ALL) standard risk. Child was full term, no birth complications. No other past medical or surgical history. Child has not received recommended 4-year-old immunizations. Physical Examination Cardiovascular: Mild tachycardia, regular rhythm, no murmur. Respiratory: Lungs clear in all fields, adequate air movement, no work of breathing. Gastrointestinal: Abdomen soft, active bowel sounds in all quadrants. Genitourinary: Adequate urine output. Last bo

Oral steroids is anticipated. Steroids are indicated in the treatment of ALL. Cranial radiation is contraindicated. Cranial radiation is only indicated for those patients with high risk ALL. Fluid restriction is contraindicated. Children with ALL require aggressive IV hydration to prevent tumor lysis syndrome. Viscous lidocaine oral rinse is contraindicated. Viscous Lidocaine may increase the risk of aspiration in children. Varicella vaccine is contraindicated. Children with any cancer diagnosis should not receive any live vaccines during treatment. Ondansetron is anticipated. Ondansetron is commonly administered to assist in the prevention of chemotherapy-induced nausea and vomiting during cancer treatments.

A nurse is teaching a class about the roles and responsibilities of a case manager. Which of the following responsibilities should the nurse include? Teaches nursing students Organizes client services following discharge Collects and utilizes data to change current practice Provides direct client care

Organizes client services following discharge The case manager communicates with the interprofessional team to coordinate client services while the client is in the health care facility and when the client is discharged.

A nurse is caring for a client who is receiving hospice care services and observes that the client's health is improving, and the client is becoming more active. What information should the nurse discuss with the client and their family? Discharge from hospice services Other therapies that are like hospice services Admission to long term care facility Obligations for continuing hospice services for a least one year

Other therapies that are like hospice services If a client's condition has improved, the client may opt to withdraw from hospice care and seek other types of medical management for their illness or discomfort. This is part of client self-determination.

A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event. The child's caregiver expects the child to use an inhaler without supervision. The nurse can apply which of the following interventions as protective factors for the child? Provide information on child development to the caregiver on when a child should be able to use an inhaler without supervision. Provide the child with a pamphlet on how to use an inhaler. Provide the caregiver with resources in the community for support. Refer the caregiver to the asthma educator. Ask the caregiver, "what worries you about your child?" Teach the child how to use the inhaler.

Provide information on normal child development to the caregiver on when a child should be able to use an inhaler without supervision is correct. Knowledge of normal development and expectations of what a child may be able to do for their own care is important to prevent neglect from a caregiver. Provide the caregiver with resources in the community for support is correct. Caregivers may be stressed with the care of a child with a chronic condition. Identifying community resources to support a caregiver is a protective nursing intervention. Refer the caregiver to the asthma educator is correct. Caregivers may not be adequately educated on caring for the child. Referring to supportive education resources is a protective nursing intervention. Ask the caregiver, "what worries you about your child?" is correct. Encouraging caregivers to discuss their child's development and health are protective nursing interventions.

A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? Quietly tell the APs that this is not appropriate. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit. Complete an incident report. Document the occurrence in a personal log.

Quietly tell the APs that this is not appropriate. The nurse has a professional duty to protect the client's confidential information. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality.

A nurse in the emergency department is caring for a client who has a mental illness. The nurse should identify that which of the following is a client right related to the Emergency Medical Treatment and Labor Act (EMTALA)? Receive medical screening and treatment Immediate transfer to a hospital of the client's choice Show proof of insurance prior to treatment Receive free medications

Receive medical screening and treatment According to the EMTALA, a client is entitled to be examined and treated in an emergency situation.

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? Discussing a client's surgical procedure with the nurse manager Reporting laboratory findings to a member of the client's family Notifying the provider of physical examination findings Identifying the client by name when making a referral for home health services

Reporting laboratory findings to a member of the client's family Confidentiality is the nondisclosure of information except to an authorized person, that is, someone involved in the client's care or someone the client has given permission for informing. Reporting laboratory findings to a family member without the client's permission violates client confidentiality.

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation? Right documentation Right time Right room Right communication

Right communication Right communication is one of the five rights of delegation. The nurse should be sure to communicate clearly and provide sufficient directions when delegating tasks.

A nurse is admitting a client who has end-stage chronic obstructive pulmonary disease (COPD) and has been intubated on previous hospitalizations. The client refuses intubation and any invasive treatment. Which of the following client rights is the client exercising? Right of confidentiality Right of justice Right to medical records Right of autonomy

Right of autonomy The client is exercising their right to determine their own care and treatment. The nurse should advocate for the client and support the client's right of autonomy or self-determination.

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? Right circumstances Right communication Right person Right supervision

Right supervision The nurse is demonstrating the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed.

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? Logging out of the computer before leaving a terminal Sharing computer passwords with coworkers Using a computer terminal in a non-public area Preventing an unidentified health care worker from viewing a health record on the computer screen

Sharing computer passwords with coworkers This action violates client confidentiality by allowing coworkers to access information which they may not be authorized to view.

A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal? Stage 3 (severe) Stage 2 (moderate) The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal. Stage 1 (mild)

Stage 3 (severe) Stage 3 withdrawal includes disorientation, hallucinations, and seizures.

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? The AP's ability to prioritize The AP has the knowledge and skill to perform the task The AP's rapport with clients The AP's ability to complete the task without assistance

The AP has the knowledge and skill to perform the task The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? The client's partner The client The client's daughter, who is the primary caregiver The client's son, who has a durable power of attorney

The client If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.

An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for? The client who requires frequent ambulation The client who is in protective isolation The client who is actively dying and requires IV pain medication The client who is 3 days postoperative and requires a dressing change

The client who is actively dying and requires IV pain medication The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family.

A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider? The most experienced nurse receives the more complex clients Personal comfort level in making the assignments Social relationships between nurses working the oncoming shift The physiologic status of the clients on the unit

The physiologic status of the clients on the unit Making assignments requires knowing the physiologic status of the clients on the unit, such as the stability of the clients' vital signs, the amount of health education they need, and the complexity of care involved. Clients who have an unstable physiologic status may require a higher level of skilled care.

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer? Transporting a school-age client who is in traction to another department Playing a computer video game with an adolescent who has sickle cell disease Reading a book to a preschool client who has AIDS Rocking an infant who was admitted for croup

Transporting a school-age client who is in traction to another department To ensure client safety, the nurse is responsible for delegating tasks to the right people. The nurse should avoid assigning this task to the volunteer because the individual who performs this task must understand the principles of traction. A volunteer does not have the requisite skill to perform this task.

A community health nurse is providing education to a group of nurses about the functions of various government agencies. The nurse should include in the teaching that which of the following government agencies addresses food security by directly providing food to select populations? U.S. Department of Agriculture (USDA) Office of Disease Prevention and Health Promotion (ODPHP) U.S. Food and Drug Administration (FDA) U.S. Department of Health Resources and Services Administration (HRSA)

U.S. Department of Agriculture (USDA) The USDA oversees the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the school lunch program, all of which provide food to specific populations. Thus, the nurse should include this government agency as the agency that addresses food security by directly providing food to select populations.

A public health nurse is responding to a disaster and is following the eight domains of Core Competencies in Disaster Nursing by the International Council of Nurses. Which of the following actions should the nurse take within the domain of safety and security? Participate in debriefing for those who responded to the disaster Respectfully manage a large number of deceased clients Wear personal protective equipment (PPE) when necessary Provide first aid to those affected by the disaster

Wear personal protective equipment (PPE) when necessary Infection control is part of the domain of safety and security. The nurse should follow basic infection control practices, such as wearing PPE to mitigate the spread of infection, so as not to hinder disaster response efforts.

A nurse manager has asked other nurses to contribute to the performance appraisal of a newly licensed nurse. Charge Nurse 2 weeks ago: Appeared to go to the supply room multiple times when doing a wound dressing change. Agreed to cover other team members' clients so they could take a meal break but does not take break. 1 week ago: The nurse was reviewing client assignment 30 minutes before time to clock in for work. Shift report and client update to charge nurse are written in notes on many small pieces of paper. Waited until end of shift to document on each client Nurse on Same Shift 2 weeks ago: Observed in medication room on personal phone multiple times during shifts. 1 Week ago: Volunteers to cover other nurses' clients for breaks but does not take breaks. States they do not like to bother others by asking for help. Nurse on Following Shift 3 weeks ago: Bedside shift reports are not well organized with det

When evaluating outcomes for a performance appraisal for a newly licensed nurse, the nurse manager determines that time management requires organization of work, prioritization, and reprioritization throughout a shift. When time management is poor a nurse's self-care may be jeopardized by missed breaks or staying after scheduled hours to complete tasks or charting. Delegation is a skill and art that a nurse must learn and requires the use of nursing judgement to delegate client care to other healthcare team members as well as knowing when circumstances are not right to accept a delegated task. Professional behaviors are aspects of professionalism and professional comportment. This includes participation in nursing care through adhering to the workplace requirements including use of personal phone, ensuring all orders are followed and taking breaks.

A nurse is reviewing admission assessment and plan of care for a client who has Crohn's disease. Admission Assessment A 20-year-old admitted through emergency department who is experiencing an exacerbation of previously diagnosed Crohn's disease. Client has lost 6.8 kg (15 lb) over the past week and is too nauseated to keep anything down today. They noticed blood in their stool three days ago. Repeatedly stated to staff, "I do not want to live like this. I am totally frustrated with all you medical people." Assessment: Right lower quadrant abdominal pain, abdominal bloating, diarrhea (mucus and blood present), perianal abscess. Vital Signs: Temperature 37.5° C (99.5° F) Heart rate 78/min Respiratory rate 20/min Blood pressure 102/54 mm/Hg Provider Prescriptions Medical management CBC, CMP, ESR (erythrocyte sedimentary rate) MRE (magnetic resonance enterography) of pelvis and abdomen Corticosteroids for clinica

When generating solutions, the nurse anticipates working with an interdisciplinary team. This is considered a core competency of patient-centered care. Key is the nurse's understanding of roles and responsibilities within the team. This is increasingly important when planning care for clients with disorders like Crohn's Disease. Pharmacists educate and review the medications. Gastroenterologists are specialist providers who specialize in treating disorders of the digestive tract. Registered dietitian provides nutritional and dietary management and goals for clients. General Surgeon may be needed if closure or drainage of perianal abscess is needed. Radiologists are medical providers who diagnosis disease and injury using medical imaging such as the MRE. Social Workers assist clients with discharge planning, reimbursement and can also be clinical social workers who can assist clients with mental, behavioral or emotional problems.

A team of school nurses is planning to advocate for students who will be affected by a proposed law. When should the nurses plan to analyze the law to advocate for the students? When the bill is proposed to the legislature When the executive branch signs the bill into law When the bill is being developed by legislators When a percentage of students has been affected by the law When parent and teacher organizations post about the law on social media sites

When the bill is proposed to the legislature is correct. The nurses should determine that, as advocates, they should engage in policy making at every level of the policy making process, which begins when the bill is proposed. When the executive branch signs the bill into law is correct. The nurses should determine that, as advocates, they should engage in policy making at every level of the policy making process, which ends when the bill becomes a law. When the bill is being developed by legislators is correct. The nurses should determine that, as advocates, they should engage in policy making at every level of the policy making process, which includes while the bill is undergoing changes in the legislature.