leadership
A home health nurse is planning her daily visits and receives lab results for our four adult clients. The nurse should first visit the client who has which of the following values? A. dig 1.0 B. WBC 6,000 C. Platelets 100,000 D. Potassium 4.0
C. Platelets 100,000
nurse is caring for a client who is experiencing adverse effects after receiving a new medication. Which of the following communication tools should the nurse use for management of this complication? A. Critical pathway B. Incident reporting C. SBAR framework D. Root cause analysis
C. SBAR framework
A nurse is caring for a client who requests pain meds. The nurse fulfills a promise to return with the meds within 15 mins. The nurse is demonstrating which of the following ethical principles? A. beneficience B. utility C. justice D. fidelity
D. fidelity
A nurse manager is auditing client charts and identifies an increase in ventilator-associated pneumonia. Which of the following actions should the nurse manager take? A. report the findings to the hospital ethics committee B. alert central supply C. fill out an incident report D. notify the quality improvement team
D. notify the quality improvement team
A nurse is caring for a client who report vomiting and diarrhea for the past 6 hours. The nurse should identify that which of the following assessments is priority? A. auscultate the clients bowel sounds B. measure the clients temp C. check the clients urine specific gravity D. obtain the clients serum potassium level
D. obtain the clients serum potassium level
A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes. The nurse should recommend a referral for the client to which of the following members of the interprofessional team? A. podiatrist B. social worker C. paramedical tech D. occupational therapist
D. occupational therapist
A nurse is caring for a client who is scheduled for rotator cuff surgery. The client tells the nurse, "My shoulder doesn't hurt that badly. I want to wait on the surgery." Which of the following responses should the nurse give? "I will notify your provider of your decision." "It's too late to change your mind once the consent form is signed." "Don't be nervous. You'll feel better after the surgery." "If you don't have the surgery, your condition will become worse."
"I will notify your provider of your decision."
A charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects an intrapersonal conflict? "I'm not sure whether I want to apply for the unit manager's position or start a family this year." "I feel frustrated because I just readmitted a client who refuses to take their insulin." "The unit manager is more concerned with saving money than with clients getting quality care." "Every time I request an extra day off I'm denied, but other nurses' requests are approved."
"I'm not sure whether I want to apply for the unit manager's position or start a family this year."
A nurse is speaking with the adult child of a client who has severe Alzheimer's disease. The child is crying and tells the nurse, "I don't know how much longer I can keep this up." Which of the following responses should the nurse make? "I understand how you must be feeling." "You should speak with your parent's doctor about this." "Let's discuss options for respite care." "You'll need to get help if your parent becomes combative."
"Let's discuss options for respite care."
A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? "I cannot make changes to my advance directives once the document is final." "These will outline my wishes for medication treatment." "My partner will need to be present if I become unresponsive." "My provider will make my health care decisions if I am unable."
"These will outline my wishes for medication treatment."
A charge nurse is managing conflict with a staff nurse who does not agree with the client care assignment. Which of the following statements is an example of using the conflict resolution strategy known as smoothing? "Would you accept the assignment if we reassign your client who has total care needs and assign another client who can provide more self-care?" "Tell me what changes we need to make so that you'll feel comfortable with the assignment." "I didn't mean to make you feel overwhelmed. Why don't you look over the assignments with me and suggest changes?" "You always complete your work on time and do a great job. I believe you can handle the assignment well."
"You always complete your work on time and do a great job. I believe you can handle the assignment well."
A charge nurse notices that a newly hired nurse consistently does not finish client care tasks by the end of the shift. Which of the following statements should the charge nurse make? "You should set aside time to plan your day at the beginning of each shift." "You should take an extended break once your documentation is completed." "You should prioritize your tasks according to your personal preferences." "You should save your charting for the end of the shift."
"You should set aside time to plan your day at the beginning of each shift."
A nurse is teaching a client about the Patient Protection and Affordable Care Act and their rights regarding insurance coverage. Which of the following statements by the client indicates an understanding of the teaching? A. "My insurance coverage no longer has lifetime coverage limits." B. "I can provide health insurance coverage for my children on my policy until they turn 21 years old." C. "My insurance will not provide coverage for preexisting conditions." D. "I can lose my insurance coverage since I have been sick so much this year."
A. "My insurance coverage no longer has lifetime coverage limits."
A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching? A. "change of shift report can be given at client's bedside' B. "I can provide client info over the phone if the caller identifies themselves as family" C. "a client cannot see their medical record because it is considered to be property of the facility' D. "access to client info is limited to direct care providers'
A. "change of shift report can be given at client's bedside'
There has been a massive community disaster and stable clients must be discharged from a facility to prepare for the influx of new casualties. A nurse should identify that which of the following clients is safe to discharge? A client who has multiple sclerosis and reports ataxia A client who has deep-vein thrombosis and an aPTT within the expected reference range A client who has right lower quadrant pain and positive rebound tenderness A client whose amylase and lipase levels are twice the expected value
A client who has multiple sclerosis and reports ataxia
A CNA tells a charge nurse that it is unfair they have to take care of all the client's who are incontinent. Which of the following responses should the charge nurse make? A. "I delegate tasks to personnel based on their job description" B. "Everyone working here has to care for clients who are incontinent" C. "Let's talk about organizing workflow so you care for fewer of these clients" D. "why do you not want to care for clients who are incontinent"
A. "I delegate tasks to personnel based on their job description"
A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? A. A nurse is photocopying their assigned client's diagnostic results B. A CNA documents a client's vitals on the client's paper-based graphic record C. The unit secretary faxes a client's lab results to the provider D. An RN stays with a client who is reading the medical records that were requested
A. A nurse is photocopying their assigned client's diagnostic results
A charge nurse is observing a newly licensed nurse care for a client who has a prescription for application of an aquathermia pad to the right lower leg. Which of the following actions should indicate to the charge nurse that the nurse understands how to use the device? (Select all that apply.) A. Asks the client to report if the aquathermia pad gets too warm B. Checks the client's leg 30 min after applying the aquathermia pad C. Shows the client how to adjust the temperature D. Ensures that the client's call light is in reach E. Decreases the temperature by 2.8° C (5° F) if the client's skin becomes reddened
A. Asks the client to report if the aquathermia pad gets too warm D. Ensures that the client's call light is in reach
A nurse is providing preop teaching for a client who is scheduled for a total knee arthroplasty and speaks a different language. Which of the following interprofessional team members should the nurse include in the discussion? A. Interpreter B. Social worker C. Occupational therapist D. Spiritual advisor
A. Interpreter
33. A staff nurse detects alcohol on the breath of another nurse working on the unit. The staff nurse observes that the nurse's speech is slurred and their gait is unsteady. Which of the following actions should the nurse take? A. Notify the charge nurse of the nurse's behavior. B. Confront the nurse about their behavior. C. Wait to see if the behavior occurs again before acting. D. Suggest the nurse request sick leave for the rest of the shift.
A. Notify the charge nurse of the nurse's behavior.
54. An RN delegates the task of obtaining the blood pressure of a client who is 2 hr postoperative following a cholecystectomy to a licensed practical nurse (LPN). The LPN reports a blood pressure that is significantly higher than the client's previous reading. Which of the following actions should the RN take first? A. Recheck the client's blood pressure. B. Treat the client's blood pressure with a prescribed antihypertensive. C. Ask the LPN to review the technique for obtaining blood pressure. D. Review the client's medical record for other episodes of elevated blood pressure.
A. Recheck the client's blood pressure.
A nurse walks into the nurse's station and sees several staff members are looking at the EHR for a celebrity client on another unit. Which of the following actions should the nurse take first? A. Remind the staff members that this is a breach of confidentiality B. Discuss the issue with the nurse manager C. Request that an administrative restriction be placed on the client's record access D. Prepare a memo for the facility ethics committee
A. Remind the staff members that this is a breach of confidentiality
A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority? A. The child has red fissures at the corners of their mouth B. The child has several small bruises on both legs C. The child sleeps for about 13 hours each night D. The child is not regularly attending school
A. The child has red fissures at the corners of their mouth
A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take? A. assist in weighing the options involved in the decision B. provide a legal representative for the family C. recommend the best course of action for the client D. decide how the nursing team should resolve the dilemma
A. assist in weighing the options involved in the decision
A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first A. assist the clients who are in the immediate danger to a safe location B. close the doors and windows on the unit C. attempt to extinguish the fire using an ABC extinguisher D. discontinue the oxygen use for clients who can breathe without it
A. assist the clients who are in the immediate danger to a safe location
A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure ulcers in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan? A. compare data from client's records regarding skin integrity with established criteria B. measure staff attendance at an educational program on managing pressure injuries C. interview clients regarding their satisfaction with their care D. monitor use of supplies used to prevent pressure injuries
A. compare data from client's records regarding skin integrity with established criteria
A nurse manger needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing this issue. A. inform the staff of the penalties that can result from med errors B. encourage the staff to have two nurses verify med orders to prevent errors C. provide suggestion boxes for nurses to submit ideas for error prevention D. ask three experienced nurses to help investigate common causes of the errors
A. inform the staff of the penalties that can result from med errors
A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the new nurse to take? A. place the client in a dorsal recumbent position for exam B. auscultate for vascular bruits with the diaphragm of the stethoscope C. begin the assessment by using light palpation over the abdomen D. ensure that the client has a full bladder before beginning the procedure
A. place the client in a dorsal recumbent position for exam
A hospice nurse is planning care for a client who does not have advance directives. Which of the following interventions should the nurse include in the plan of care? A. provide the client with information about advance directives B. encourage the client to contact an attorney to create advance directives C. inform the client that they will need a relative to witness their advance directives D. tell the client that the Joint Commission requires clients to have advance directives
A. provide the client with information about advance directives
A nurse is reviewing safe use of a wheelchair with a group of CNAs. which of the following instructions should the nurse include? A. raise the footplate of the wheelchair before transferring the client B. lock the brakes on one wheel of the chair when transferring the client C. push the wheelchair into the elevator with the front wheels first D. stand behind the wheelchair when moving a client down a ramp
A. raise the footplate of the wheelchair before transferring the client
A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following should the charge nurse do? (Select all that apply.) A. role model a positive approach to the changes B. redirect the conversation when staff members make negative comments about the changes C. encourage staff members who support the changes to discuss the issue with resistant staff D. suggest that resistant staff members transfer to a different unitE. reprimand staff members who are resistant to changes
A. role model a positive approach to the changes C. encourage staff members who support the changes to discuss the issue with resistant staff
A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique A. the nurse places the sterile package with the top flap opening away from the body B. the nurse pinches the flap on the inside of the package first to open it C. the nurse reaches over the package to open the left flap D. the nurse pulls the last flap of the package away from the body
A. the nurse places the sterile package with the top flap opening away from the body
A nurse is conducting an orientation class for new clients and their families at the long term care facility. Which of the following client rights should the nurse address at the orientation? (SATA) A. the right to be treated with respect and dignity B. the right to full access of the facility C. the right to refuse their meds D. the right to leave regardless of provider recommendations E. the right to be fully informed of their health conditions
A. the right to be treated with respect and dignity C. the right to refuse their meds D. the right to leave regardless of provider recommendations E. the right to be fully informed of their health conditions
. A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated to an assistive personnel (AP)? (Select all that apply.) Flushing a client's saline lock Ambulating a client who uses a walker Adding thickener to thin liquids on a client's food tray Showing a client how to use an incentive spirometer Evaluating a client's gag reflex before mealtime
Adding thickener to thin liquids on a client's food tray Ambulating a client who uses a walker
A nurse is preparing to administer medication to a client who has Crohn's disease. The client state "I want to skip this dose of my medication. I am too tired to take it". Which of the following actions should the nurse take? A. leave the med on the client's bedside table to take later B. return in 1 hour to administer the med C. mix the med in applesauce to administer to the client D. inform the client of the consequences of refusing the med
D. inform the client of the consequences of refusing the med
A charge nurse has been asked to determine staff adherence to established standards for post-op VS measurement. Which of the following actions should the nurse take to collect information? A. Distribute a questionnaire asking staff to rate adherence to the standard B. Conduct a retrospective chart audit of all surgical clients for the past 6 months C. Ask the nurse manager to examine staff performance reviews D. Review client satisfaction surveys for all surgical clients for the past 6 months
B. Conduct a retrospective chart audit of all surgical clients for the past 6 months
Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to a CNA? A. "Take vitals every 2 hours for the client who had a cholecystectomy in room 6122' B. "Check the urinary output at 1100 for John Doe and report it to me immediately" C. "Report to me if the chest drainage is excessive for Jane Doe in room 2438" D. "Please notify me of any clients whose vital signs of blood glucose levels are significant"
B. "Check the urinary output at 1100 for John Doe and report it to me immediately"
A nurse is caring for a 19 yr old who has just been informed that their cancer has metastasized. The client tells the nurse that they do not want to continue chemotherapy. Which of the following responses should the nurse make? A. "I will have the provider discuss treatment options with your parents' B. "I will gather info about palliative care for you" C. "I will contact you spiritual advisor to discuss this decision with you' D. "I will contact your parents about becoming your designees in your durable power of attorney"
B. "I will gather info about palliative care for you"
52. A nurse is caring for a client who recently learned he has a mutation of the BRCA2 gene. The client states that he does not plan to tell his adult children about the diagnosis. Which of the following responses displays client advocacy by the nurse? A. "You should tell your children because this could affect their health as well." B. "Let's review what you understand about this test result." C. "Why would you not want to share this information with your children?" D. "I feel it would be best for you to reconsider your decision."
B. "Let's review what you understand about this test result."
A nurse is caring for a client who is hospitalized and has expressive aphasia. The client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling cath. Which of the following responses should the nurse make?A. "procedures prescribed by the provider do not require consent" B. "this is a procedure that does not require written informed consent' C. "you are right. I will discuss this issue with the charge nurse' D. "would you mind signing the informed consent form for the procedure at this time?"
B. "this is a procedure that does not require written informed consent'
.A nurse is receiving change-of-shift report. Which of the following clients should the nurse assess first? A. A client who has a WBC count of 15,000/mm3 and is receiving antibiotics B. A client who had abdominal surgery 6 hr ago and has had a heart rate of 120/min for the last 2 hr C. A client who is requesting pain medication 24 hr after an open reduction and internal fixation (ORIF) of the left ankle D. A client who has pneumonia and an oxygen saturation of 95% and is refusing prescribed medication
B. A client who had abdominal surgery 6 hr ago and has had a heart rate of 120/min for the last 2 hr
A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority? A. a client who is scheduled for a tubal ligation in 2 hours and is crying B. A client who has peripheral vascular disease and has an absent pulse in the right foot C. A client who has type 1 diabetes and needs the first dressing change for an ulcer D. A client who has MRSA and has an axillary temperature of 100.4F
B. A client who has peripheral vascular disease and has an absent pulse in the right foot
A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse? A. A client who has heart failure and 2+ edema of the lower extremities B. A client who is 2 days postoperative and has a urine output of 20 mL/hr C. A client who started taking verapamil and has a heart rate of 75/min D. A client who is receiving morphine and reports nausea
B. A client who is 2 days postoperative and has a urine output of 20 mL/hr
An RN is working on the surgical unit when a client who has abdominal pain is admitted. Which of the following activities must be performed by the RN? A. Obtain a urinalysis from the client B. Completing the client's initial admission assessment C. Administering PO pain medications to the client D. Assembling the client's medical record
B. Completing the client's initial admission assessment
A charge nurse on a medical unit hears the fire alarm and announcement that a fire is occurring on the unit. Which of the following is the priority action by the charge nurse? A. Turn off the oxygen supply valve to the unit. B. Instruct ambulatory clients to go to a safe area. C. Verify that unit fire doors are closed. D. Direct personnel to use fire extinguishers.
B. Instruct ambulatory clients to go to a safe area.
nurse is caring for a client who has a potassium level of 3.2 mEq/L. The nurse has been paging the provider for 1 hr to attempt to report the potassium level. Which of the following actions should the nurse take next? A/ Continue to attempt to contact the provider. B. Notify the nursing supervisor. C. Administer an emergency dose of potassium. D. Consult with the pharmacist.
B. Notify the nursing supervisor.
A charge nurse is planning client care assignments for a unit. Which of the following should the nurse assign the LPN? A. determine the swallowing ability of a client who had a stroke B. Provide an enteral feeding to a client with Crohn's disease C. develop a teaching plan for a client who has a new diagnosis of type 2 diabetes D. weigh a client who is 3 days postop following coronary artery bypass grafting
B. Provide an enteral feeding to a client with Crohn's disease
A nurse asks a newly hired CNA to remove a client's indwelling cath. Which of the following actions should the nurse take to ensure the CNA is qualified to perform the task? A. Show the CNA how to remove an indwelling cath B. Review the CNA's skill competency list C. Ask the CNA is they know how to remove a foley D. pair the newly hired CNA with an experienced CNA
B. Review the CNA's skill competency list
A case manger is planning an interprofessional conference for a client who is 3 days postop following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference? A. The client does not have transportation for discharge home B. The client refuses to attend physical therapy sessions C. The client's home health nurse has not completed the home assessment D. The client describes feelings of depression after family visits
B. The client refuses to attend physical therapy sessions
A nurse manager is developing a class for newly licensed nurses on strategies to promote client rights. Which of the following should the nurse manager include in the teaching? A. Spend equal amounts of time providing care for each client. B. Verify that a provider prescription is in the medical record for clients who have restraints. C. Ensure that competent clients do not leave the hospital without medical discharge. D. Present the purpose, risks, and benefits of a surgery when the provider is unavailable.
B. Verify that a provider prescription is in the medical record for clients who have restraints.
A nurse is caring for four clients. Which of the following assessment findings is priority? A. a client who has facial drooping following a stroke 8 hours ago B. a client who has a femur fracture and reports feeling short of breath C. a client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0-10 D. a client who had an open cholecystectomy 4 days ago and has serosanguinous drainage on the wound dressing.
B. a client who has a femur fracture and reports feeling short of breath
A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care? A. request crutches from a medical equipment provider B. advise the client to install grab bars in the bathroom at home C. encourage the client to allow a home care aide to perform ADL's for them D. contact hospice to provide follow-up care for the client
B. advise the client to install grab bars in the bathroom at home
A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent? A. verify that the client understands the risks of surgery B. ask the client to explain the procedure that is being performed C. answer the client's questions about the outcomes of the surgery D. determine if the client understands the benefits of the procedure
B. ask the client to explain the procedure that is being performed
A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behaviors should the charge nurse identify as an indication that the staff nurse might be working while impaired?A. spends free time conversing with other staff members at the nurse's station B. frequent use of restroom C. asks other nurses to administer pain meds for their clients D. delegates tasks to assistive personnel
B. frequent use of restroom
A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take? A. assess the client's incision q8 hours for the first 48 hours B. inform the CNA of the client's weight bearing status C. instruct the client to cross their legs at the ankles when sitting in a chair D. Teach the client's partner to assist the client to flex the hip at least 120 degrees each hour
B. inform the CNA of the client's weight bearing status
A nurse manager finds that there has been an increase in urinary tract infections on the unit. The address this problem, which of the following actions should the nurse manager take first? A. conduct an in-service that reviews proper cath insertion and maintenance B. perform a chart review to gather data about the clients who developed infections C. observe each staff nurse perform a urinary cath insertion D. require completion of a self-paced instruction program
B. perform a chart review to gather data about the clients who developed infections
A nurse is caring for a client who is 3 days post op following open heart surgery and will be transferred to the med-surge unit. Which of the following info should the nurse plan to include in the verbal report? A. the client's dressing change schedule B. the client's level of consciousness C. the client's VS from the previous shift D. the client's occupation
B. the client's level of consciousness
A nurse in a mental health facility is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "I should use mechanical restraints when a client who is manic starts pacing." B. I should document every hour when a client is in mechanical restraints." C. "I should request the provider to examine the client within 1 hour of applying mechanical restraints." D. I should check the client every 30 minutes while in mechanical restraints."
C. "I should request the provider to examine the client within 1 hour of applying mechanical restraints."
58. A nurse is delegating tasks for a group of clients to an assistive personnel (AP). Which of the following statements by the nurse provides the right direction of communication with the AP? A. "Please take the vital signs of the clients in rooms 200 through 208." B. "Obtain the weight of the client in room 202 using the bed scales." C. "Tell me what time the client in room 205 voids for the first time after the catheter is removed." D. "The client in room 201 needs to have antiembolic stockings applied."
C. "Tell me what time the client in room 205 voids for the first time after the catheter is removed."
A nurse is receiving report from the CNA assigned to the nurse's group of clients. Which of the following statements from the CNA indicates the client the nurse should assess first? A. "The client who has abdominal surgery 3 days ago is reporting feeling constipated' B. "The client who had the hip replacement reports pain as a 4 on a scale of 0-10" C. "The client who had an indwelling cath removed 8 hours ago reports inability to void" D. "The client who is scheduled for discharge today states they are ready to sign their paperwork"
C. "The client who had an indwelling cath removed 8 hours ago reports inability to void"
A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make? A. "A social worker will address your concerns after discharge" B. "You should plan to go to a skilled nursing facility after discharge" C. "Your case manager will coordinate the resources you will need' D. "You will need hospice care until you feel stronger"
C. "Your case manager will coordinate the resources you will need'
39. A nurse is caring for a client who has an informed consent form for an upcoming procedure in his health record. Which of the following actions should the nurse take to validate that the client understands the procedure? A. Review documentation by the provider of discussing the procedure with the client. B. Verify that the client's signature is on the informed consent form. C. Ask the client to verbalize the purpose, risks, and benefits of the procedure. D. Document the client's completed pre-procedure checklist in the medical record.
C. Ask the client to verbalize the purpose, risks, and benefits of the procedure.
53. A charge nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice per day. Which of the following actions should the charge nurse take? A. Perform the wound irrigation during rounds. B. Delegate the procedure to an assistive personnel (AP). C. Assign the procedure to a licensed practical nurse (LPN). D. Reschedule the procedure to be performed once daily.
C. Assign the procedure to a licensed practical nurse (LPN).
A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take? A. Inform the client of the consequences of decreased cerebral circulation B. Initiate a mental health consultation to determine why they client refuses the surgery C. Discuss the client's concerns about having the surgery D. Provide the client with information on additional treatment options
C. Discuss the client's concerns about having the surgery
A charge nurse recognizes a trend of poor attendance at monthly staff meetings. To address this issue, which of the following actions should the charge nurse take first? A. Write a memo emphasizing the importance of attending staff meetings B. Appoint a task force to promote attendance at the meetings C. Explore the reasons that staff are not attending the meetings D. Reduce the number of meetings the staff are required to attend
C. Explore the reasons that staff are not attending the meetings
A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should the charge nurse on the PACU take? A. Take extra wheelchairs to the ER B. Send PACU CNA's to help with triage C. identify stable clients for transfer to a surgical unit D. report to the command center for further instructions
C. Identify stable clients for transfer to a surgical unit
A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to a CNA? A. instruct the client how to take their BP B. Administer SQ meds C. determine a client's intake and output D. provide a status update to a client's family member
C. determine a client's intake and output
A charge nurse is leading a committee that is revising the policy for patient discharge. After developing the initial plan, which of the following actions should the nurse take next? A. set target dates for completion B. identify areas of support C. determine goals and objectives D. implement recommended strategies
C. determine goals and objectives
A charge nurse is observing a newly licensed nurse's use of time-management skills. Which of the following actions by the newly licensed nurse indicates effective use of this skill? A. Documents client tasks at the end of the shift B. gathers supplies as needed while completing an activity C. group tasks that are in the same location D. skips breaks throughout the day to complete work on time
C. group tasks that are in the same location
A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn? A. child protective services B. public health C. home health D. women, infants, and children
C. home health
A nurse is observing a new nurse perform a sterile dressing change on a client who has a central cath. Which of the following actions should the new nurse take? A. open the top flap of the sterile package towards the body B. maintain a 1.25 cm border around the edges of the sterile field C. pick up the first sterile glove by grasping the folding cuff edge D. remove soiled dressings using sterile gloves
C. pick up the first sterile glove by grasping the folding cuff edge
A nurse on a medical-surge unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures A. removal of staples from a surgical wound B. providing sputum specimen C. receiving moderate sedation D. collection of a blood specimen for ABG's
C. receiving moderate sedation
A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following info can assist the nurse in evaluating the cost effectiveness of the care? A. the age of the client B. the availability of community support groups C. the length of the client's stay D. the type of insurance the client carries
C. the length of the client's stay
A charge nurse is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions? A. "I will make sure the monitor is turned off when I have to leave the computer terminal." B. "I can share my password with nursing students assigned to my unit." C. "I will allow a client to make changes directly to their medical record." D. "After I finish with the printout of my assignment, I'll put it in the shredder receptacle."
D. "After I finish with the printout of my assignment, I'll put it in the shredder receptacle."
A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "A nurse can provide basic treatment information to the client's employer" B. "A nurse can inform the client about their risks and benefits of ECT" C. "Clients on a mental health unit who are admitted voluntarily cannot leave against medical advice" D. "Clients on a mental health unit can refuse their meds"
D. "Clients on a mental health unit can refuse their meds"
A client who has back pain presents to the ER and is provided a prescription for oxycodone. A staff nurse tells the charge nurse they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make? A. "It sounds like nonpharmacological interventions would be best for this patient" B. "Let's withhold the oxy until we can consult with the provider" C. "contact mental health services to arrange a consultation" D. "clients are the experts on their own pain"
D. "clients are the experts on their own pain"
A client on a general surgical unit tells a nurse that staff members are not answering the call light properly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first? A. notify the charge nurse of the client's request for transfer B. Assure the client that their concern has been shared with staff C. Tell the client that future calls will be answered in a timely manner D. Ask the client to verbalize their expectations
D. Ask the client to verbalize their expectations
A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease? A. RSV B. MRSA C. C-diff D. Chlamydia trachomatis
D. Chlamydia trachomatis
A client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a peripherally inserted central catheter (PICC) line. Which of the following actions should the case manager perform prior to discharge? A. Assess the client's home environment for possible reservoirs of infection. B. Verify the patency of the PICC line. C. Provide dressing change and wound assessment teaching. D. Ensure that home infusion therapy has been arranged.
D. Ensure that home infusion therapy has been arranged.
24. A nurse is planning discharge care for a client who has rheumatoid arthritis and has difficulty buttoning clothing. Which of the following referrals should the nurse recommend for the client? A. Pain management clinic B. Physical therapy C. Arthritis support group D. Occupational therapy
D. Occupational therapy
A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplants. Which of the following instructions should the nurse manager include in the teaching? A. Assign two clients who have had a stem cell transplant to the same room B. Obtain a rectal temp on client's q4 hours C. Wear an N95 respirator mask while caring for these clients D. Place clients in positive pressure airflow rooms
D. Place clients in positive pressure airflow rooms
A charge nurse is evaluating a plan of care that a newly licensed nurse developed for a client who is to receive a continuous NG tube feeding. Which of the following interventions should the charge nurse ensure is part of the plan of care? A. Flush the tube every 8 hr with 0.9% sodium chloride irrigation. B. Use an acidic juice to unclog a blocked tube. C. Add dissolved medications to the enteral feeding. D. Use a 60-mL syringe to flush out a clogged tube.
D. Use a 60-mL syringe to flush out a clogged tube.
A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse? A. a client who is in balanced skeletal traction B. a client who had a total hip arthroplasty 3 days ago C. a client who had a fractured femur with a new cast D. a client who had a right above the knee amputation 24 hours ago
D. a client who had a right above the knee amputation 24 hours ago
A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first? A. a client who has a penetrating head injury and respiratory rate of 4/min B. a client who has a comminuted fracture of the femur C. a client who has a 15.2 cm laceration to the scalp with clotted blood visible D. a client who has a sucking chest wound
D. a client who has a sucking chest wound
Two nurses on a unit each contend that the other is not doing a fair share of work. The conflict is affecting the functioning of the unit. A charge nurse should approach this conflict is which of the following ways? A. schedule the nurses to work on alternating shifts B. organize a task force to evaluate the situation C. tell the nurses that it is their responsibility to cooperate with coworkers D. explore the alternative solutions to address unit workflow with the nurses
D. explore the alternative solutions to address unit workflow with the nurses
A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take? A. insert the tube and begin feedings per family's request B. ask the provider to discuss the issues with the family C. report the dilemma to the facility's dietician D. review the client's request with the family
D. review the client's request with the family
A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted catheters in the ICU. Which of the following resources should the nurse consult in planning for this policy. A. national league for nursing B. American academy of nursing C. agency for healthcare research and quality D. state nurse practice act
D. state nurse practice act
A charge nurse is observing a new nurse who is caring for a client who has pulmonary TB. The charge nurse should expect the new nurse to take which of the following actions? A. place the client on droplet precautions B. place the client in a room with positive pressure airflow C. wear a surgical mask when taking the client out of the room D. wear and N95 respirator mask when in the client's room
D. wear and N95 respirator mask when in the client's room
A nurse manager is completing a performance improvement audit and determines documentation of client discharge teaching is below the expected benchmark. Which of the following actions should the nurse implement first? Offer incentives for the staff once the unit's benchmark is above average. Train specific nurses to use a standard discharge teaching plan. Determine the factors that interfere with the documentation of client education. Include client discharge teaching as part of the annual performance evaluation.
Determine the factors that interfere with the documentation of client education.
60. A nurse on a medical-surgical unit is caring for a client who is terminally ill. Which of the following actions demonstrates that the nurse is practicing in an ethical manner when caring for the client? A. Limit visitors when the client is in acute pain. B. Discuss end-of-life care goals with the client. C. Instruct the family to avoid touching the client. D. Inform the client of an approximate time of death.
Discuss end-of-life care goals with the client.
A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take? Provide info about alternative birth control methods Ask If the client has discussed the decision with their partner Emphasize benefits of procedure Discuss the clients feelings about the procedure.
Discuss the clients feelings about the procedure.
A nurse us teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. " I should place a copy of an incident report in the client's medical record." B. I should document the completion of an incident report in the client's medical record C. I should complete an incident report for an unexpected client outcome D. I should ask the risk manager to complete to incident reports
I should complete an incident report for an unexpected client outcome
A nurse is teaching an assistive personnel (AP) about caring for a client who has a do-not-resuscitate (DNR) order. Which of the following statements by the AP indicates an understanding of the teaching? A. "If I cannot detect the client's pulse, I will have another AP verify this with me." B. "If the client does not have a pulse, I will call for the rapid response team." C. "I will initiate CPR until a nurse arrives if I cannot detect the client's pulse." D. "I will call for the client's nurse to come to the room if I cannot detect the client's pulse."
I will call for the client's nurse to come to the room if I cannot detect the client's pulse."
. A nurse manager is conducting an annual performance review for a staff nurse. Which of the following strategies should the nurse use in the review process? (Select all that apply.) Base the review on the nurse's performance during the past 90 days. Include peer evaluations completed by other staff nurses. Evaluate the nurse's performance based on a comparison of the nurse to others on the unit. Have the nurse conduct a self-appraisal prior to the review. Complete a performance checklist.
Include peer evaluations completed by other staff nurses. Have the nurse conduct a self-appraisal prior to the review. Complete a performance checklist.
nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2 hr. The client tells the nurse that she has called a taxicab and is leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next? Have the client sign the "Against Medical Advice" (AMA) form. Inform the client about the risks she may encounter by leaving the facility. Document the client's statements in the medical record. Notify the risk manager.
Inform the client about the risks she may encounter by leaving the facility.
A nurse manager is reviewing the stages of conflict resolution with the nursing staff. The nurse manager should instruct the staff to expect the stages of the conflict to occur in what order? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
LatentPerceivedFelt ConflictManifest ConflictConflict aftermath
A public health nurse is developing a list of recommendations for her supervisor on how to use EBP to improve community outcomes. Which of the following should the nurse recommend as a qualitative research method? A. Meta-analysis B. Experimental study C. Phenomenology D. Secondary analysis
Phenomenology
A nurse overhears two staff members in the facility elevator discussing a client's care. Which of the following actions should the nurse take? Clarify the client information the staff members are discussing. Send the staff members home for the day. Report the incident to the nurse manager. Inform the client about the breach of confidentiality.
Report the incident to the nurse manager.
A nurse at an urgent care clinic notices that a pain assessment is not being performed for all clients as required by policy. Which of the following actions should the nurse take to ensure care is provided according to policy? Check client satisfaction surveys for feedback on this issue. Post an article on pain assessment on the bulletin board. Document this finding on an incident report. Report this issue to the nurse manager.
Report this issue to the nurse manager.
A nurse on a med-surge unit has arrived late to work multiple times over the past several weeks. Identify the sequence the nurse manager should follow when disciplining the employee:
Schedule a meeting with the nurse provide a written reprimand temporarily remove the nurse from scheduled shifts terminate the nurse's employment
