Leadership and Management

When caring for a client with pneumonia, which nursing activities are most appropriate for the registered nurse to delegate the licensed practical nurse working under RN supervision? Select all apply 1. Administering metered dose inhaler medications 2. Monitoring lung sounds 3. Evaluating the use of incentives spirometer 4. Nasotracheal suctioning to collect the sputum specimen 5. Teaching the importance of fluid intake

1. Administering metered dose inhaler medications 2. Monitoring lung sounds 4. Nasotracheal suctioning to collect the sputum specimen: The RN is responsible for an initial instruction on the importance of fluid intake and for evaluation of proper incentives spirometer use. The RN can safely delegate certain aspects of nursing care for stable clients to the LPN.

The nurse prepares to teach an in-service on legal issues related to nursing. Which legal terms are followed by inappropriate example? Select all that apply 1. Assault: Threatening to administer a benzodiazepine if the client does not comply 2. Battery: Misinforming a client that a painful injection will not create discomfort 3. False imprisonment: storing a competent client's clothes to prevent the client from leaving prior to a prescribed treatment 4. Informed consent: Calling the parent of an emancipated minor for approval prior to providing care 5. Invasion of privacy: Posting a medical update on the social media page of a client is a friend

1. Assault: Threatening to administer a benzodiazepine if the client does not comply 3. False imprisonment: storing a competent client's clothes to prevent the client from leaving prior to a prescribed treatment 5. Invasion of privacy: Posting a medical update on the social media page of a client is a friend: Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched. False imprisonment is the confinement of a client against the clients will or without legal justification Invasion of privacy includes disclosing medical information to others without client consent Battery involves making physical contact with the client without permission. This includes harmful acts or acts the client refuses. An emancipated minor is an individual under the age of legal responsibility who has been legally freed from parental control through a court order. The parent in this situation would not need to be called.

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply 1. Before liver biopsy, pulse is 80/min and BP is 120/80; 1 hour afterward, pulse is 112/min and BP is 90/60. 2. Before lumbar puncture, pulse is 100/min and BP is 140/86; 1 hour afterward, pulse is 80/min and BP is 126/82. 3. Client with CAD on metoprolol; pulse is 62/min 4. Elderly client with black stool; pulse is 112/min 5. Neonate crying inconsolably at feeding time; pulse is 160/min

1. Before liver biopsy, pulse is 80/min and BP is 120/80; 1 hour afterward, pulse is 112/min and BP is 90/60. 4. Elderly client with black stool; pulse is 112/min: Black stools indicate slow upper GI bleed; tachycardia may indicate significant blood loss. Therefore, this client needs immediate assessment. VS changes are early signs of concern for hypovolemic shock are tachypnea, tachycardia, and agitation; hypotension is a late finding.

Which of these tasks are appropriate for the RN to delegate to the UAP? Select all that apply. 1. Assign lunch time to the other UAP on the unit 2. Assist a client with a new ostomy with bathing and changing pouches 3. Collect vital signs on a client 4 hours after a laparoscopic appendectomy 4. Pick up an intravenous antibiotic from pharmacy 5. Record I/O's for a client with metabolic alkalosis

3. Collect vital signs on a client 4 hours after a laparoscopic appendectomy 4. Pick up an intravenous antibiotic from pharmacy 5. Record I/O's for a client with metabolic alkalosis: The UAP may gather information (VS, I/O's) about stable clients, assist stable clients with ADL's, and retrieve necessary supplies, but the RN retains accountability for all delegated actions and outcomes.

Which of the following are violations of protective client health information? Select all that apply 1. Client overhears the nurse gave report on the clients roommate through the curtain 2. Nurse calls a client by the first and last names in the public waiting room 3. Nurse gives a pregnancy test results to the client partner without clients permission 4. Nurse tells the transporting tech that the client has breast cancer 5. UAP tells a discharge client, "you take care now!"

3. Nurse gives a pregnancy test results to the client partner without clients permission 4. Nurse tells the transporting tech that the client has breast cancer: The HIPPA, PIPEDA Requirements related to protected health information includes not giving results to espouse without permission or telling the clients diagnosis to an employee who does not need to know it. It is not a violation to call clients by their names, have information overheard inadvertently, or indicate well wishes

A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply 1. occupational therapy will help me learn how to properly use my walker 2. Physical therapy will help me learn how to dress myself again 3. Social services can help me find resources for affording my medications 4. Speech therapy will teach me how to eat my meals properly 5. Wound care will teach me how to properly address this wound on my knee

3. Social services can help me find resources for affording my medications 4. Speech therapy will teach me how to eat my meals properly 5. Wound care will teach me how to properly address this wound on my knee: -Speech therapy focuses On speech and communication but also on swallowing/feeding issues. -Social workers assist with developing coping skills, securing adequate financial resources or housing, And making referrals to volunteer organizations -Wound care Is a resource for assessing and planning the optimal care of any wound -Occupational therapy emphasizes the skills necessary for ADLs (Dressing, bathing, cognitive or perception issues); However Walker training is performed by physical therapist -Physical therapy focuses on mobility, ambulation, ability to transfer and use of related equipment

The charge nurse in the coronary Care unit must transfer a client to the medical unit to accommodate another acutely ill client from the emergency department. The nurse suggested transfer of which client to the healthcare provider? 1. 52-year-old with unstable angina and chest pain at rest who has had three normal serum troponin 1 levels. 2. 60-year-old with new onset atrial fibrillation of 140 per minute who is receiving a continual IV infusion of diltiazem 3. 65-year-old admitted last night for third degree heart block who is awaiting permanent pacemaker placement 4. 78-year-old with end-stage heart failure and injection fraction of 15% whose family is requesting palliative care

78-year-old with end-stage heart failure and injection fraction of 15% whose family is requesting palliative care: Palliative and end of life care for end-stage heart failure focuses on client centered interventions to provide symptom in pain relief, rather than on curative interventions. Palliative care can be provided in any healthcare setting. Clients with unstable angina experiencing chest pain in clients newly admitted with complete heart block or atrial fibrillation with a rapid ventricular response are unstable and require continual monitoring in an intensive care unit.

I nurse is admitting A client who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child? 1. A client recovering from a ruptured appendix 2. A client with cystic fibrosis 3. A client with minimal change nephrotic syndrome 4. A client with a rheumatic fever

A client with minimal change nephrotic syndrome: Leukemia is a cancer of the blood and organs involved in hematologic function. Due to my live no suppression, clients are at risk for problems related to infection, anemia, and bleeding.

The nurse is caring for clients on a busy medical surgical unit. Which client would be priority to assess first? 1. A client with an ileostomy bag that has leaked stool all over 2. A client with chronic COPD, diminished breath sounds, and SpO2 of 91% 3. A client with deep venous thrombosis who missed the last warfarin dose 4. A client with sepsis who is developing petechiae

A client with sepsis who is developing petechiae: DIC results from abnormal activation of clotting cascade followed by consumption of clotting factors and platelets; this quickly leads to life threatening external and internal bleeding. Any signs of DIC should be assessed immediately as emergent replacement of clotting factors, blood, and platelets is needed to save the client.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain 2. Severe lower back pain after lifting heavy boxes 3. Sharp calf ache with ambulation that improves with rest 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip

Abrupt, tearing, moving (upper to lower) back pain and epigastric pain: An aortic dissection, which classically includes moving, "ripping" back, is a medical emergency. Hypertension is the important contributing factor.

After relieving the shift report, the nurse should assess which infant first? 1. An infant born 6 hours ago after 38 weeks gestation who has respirator rate of 52/min 2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago 4. An infant wrapped in a warm blanket 15 minutes ago due to temperature of 97.7

An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL: The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring the blood glucose level. A blood glucose level <40mg/dL indicates hypoglycemia and should be treated immediately by feeding or administering a glucose bolus. Normal blood glucose for an infant is 40-60mg/dL

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a causative chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurses priority action? 1. Assess the skin to determine severity of burns and wounds 2. Assign client to a cot with similarly triaged clients 3. Assist the client to the designated showering area 4. Prepare supplies to establish intravenous access

Assist the client to the designated showering area: Decontamination is a priority nursing action for clients who have been exposed to a chemical or radioactive agent. During a mass casualty disaster, The nurse should assist clients with complete decontamination before providing care. Decontamination limits further client injury and prevent exposure to other clients and staff.

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power of attorney to provide consent for the additional procedure 3. Document that an additional hernia was found and that it will require surgery at a later time 4. Witness an additional consent after both procedures are complete and the client is awake

Call the client's medical power of attorney to provide consent for the additional procedure: The three principles of informed consent include: 1. The surgeon explains the diagnosis, planned procedure The risks and benefits, expected outcome, Alternative treatments, and prognosis without surgery 2. The client indicates understanding of the information 3. The client is competent and gives a voluntary consent Clients unconscious or under the influence of mind altering drugs cannot provide consent. If sedated clients require procedures not listed on the consent form, the clients medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explained the situation and obtain consent.

The chargers on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse? 1. Client two days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void 2. Client being discharged after deep vein thrombosis who needs teaching on how to self administer an enoxaparin injections 3. Client who has just been admitted to the telemetry unit from the emergency department with a rule out myocardial infarction 4. Client with a nitroglycerin in fusion with prescription to titrate to keep systolic blood pressure less than 150 mmHg; Currently is 110/62 mmHg

Client two days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void: The charge nurse should assign the most stable and predictable client to the LPN. Clients who are less predictable and stable require clinical assessment and judgment and should be assigned to the RN

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? 1. Client with BP of 90/70 and a deviated trachea 2. Client with concussion who was unconscious for 5 minutes 3. Client with grossly swollen upper thigh and a BP of 80/60 4. Client with pain at the thoracic spin and complete paralysis of both legs

Client with BP of 90/70 and a deviated trachea: Tension pneumo causes marked compression and shifting of mediastinal structures (tracheal deviation) including the heart and great vessels, resulting in reduced CO and hypotension. This is a life threatening emergency that requires urgent large bore needle decompression followed by chest tube placement.

A nurse receives information in a change of shift report. Which client is the priority? 1. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood tinged sputum 3. Client with a femoral external fixator who has a temperature of 100.9 F and redness and pain around the pin sites 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul smelling, fatty stools

Client with a femoral external fixator who has a temperature of 100.9 F and redness and pain around the pin sites: Signs and symptoms of infection (fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment with antibiotics as these can progress to osteomyelitis a serious bone infection

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessement? 1. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2mg/dL and refuses to take prescribed medications? 2. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain 3. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage 4. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting: Intestinal obstruction and strangulated bowel are life-threatening complication associated with an incarcerated hernia and require immediate evaluation and urgent surgical intervention. Manifestations of bowel obstruction are (pain, distention, N/V)

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? 1. Client one day post thoractomy Wedge resection who has subcutaneous emphysema at the chest tube insertion site 2. Client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago 3. Client with COPD exacerbation who is receiving BIPAP therapy and has a pulse ox reading of 90% 4. Client with leg cellulitis following a spider bite who needs the IV restarted to initiate prescribed antibiotics

Client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago: Nurses should prioritize assessing clients with asthma who reports unrelieved shortness of breath within 15 minutes of nebulizer treatment with albuterol as their needs are urgent due to the risk of severe pulmonary complications.

Which ED client would be allowed to leave AMA after the risks are discussed with the primary HCP? 1. 5 year old client with meningitis whose parent refuses antibiotics 2. Client who tried to commit suicide by taking a handful of tylenol an hour ago 3. Client with a UTI who is disoriented to time and place 4. Client with coffee ground emesis from chronic use of high dose aspirin

Client with coffee ground emesis from chronic use of high dose aspirin: Issues that can make a client ineligible to leave AMA include danger to self or other, lack of consciousness, altered consciousness, mental illness, being under chemical influence or a court decision. Parents may not refuse limb, life, or organ saving treatment for a minor child based on their own personal beliefs.

The nurse recieves handoff of care report on four clients. Which client should the nurse assess first? 1. Client who had appendectomy today and reports severe nausea and 8 out of 10 pain 2. Client with diabetic foot ulcer who has current blood glucose level of 301 mg/dL 3. Client with fever of unknown origin whose arterial blood gas reveals PaCO2 30mmHg 4. Client with persistant diarrhea who has continuous LR solution IV infusing at 125 ml/hr

Client with fever of unknown origin whose arterial blood gas reveals PaCO2 30mmHg: SIRS is a pathophysiologic response to inflammatory cytokine release from the inflammatory cascade (trauma, tissue ischemia, infection) that may rapidly progress to hemodynamic instability, respiratory failure, and multi-organ dysfunction. Clinical manifestations of SIRS include fever/hypothermia, tachypnea, or low PaCO2, tachycardia, and leukocytosis or leukopenia.

Which client is most appropriate for the 7 AM to 7 PM charge nurse On a cardiac step down unit to assign to a float registered nurse from a medical surgical unit? 1. Client who just returned to the unit after coronary angioplasty and placement of a stent 2. Client with atrial fibrillation scheduled for an electrical cardioversion this afternoon 3. Client with heart block scheduled for pacemaker placement this afternoon 4. Client with heart failure and deep venous thrombosis receiving in an IV infusion of heparin

Client with heart failure and deep venous thrombosis receiving in an IV infusion of heparin: The most appropriate assignment for the float nurse is the client with heart failure in IV heparin. The nurse from a general medical surgical unit should be familiar with the assessment, nursing care, nursing diagnosis, and the medications administered to a client with heart failure and with the facilities protocol for administration of a continual IV heparin infusion

A nurse working in the office of the healthcare provider must respond to client telephone messages. The nurse should return which call first? 1. Client with the left shoulder sling due to a fractured clavicle, Reports nausea after taking oxycodone 2. Client with the right leg cast applied yesterday for her fractured ankle, Reports tingling in the right foot 3. Client with diabetes, reports having taken usual dose of insulin this morning and is now vomiting 4. Client with fibromyalgia who is prescribed amitriptyline, Reports continued insomnia

Client with the right leg cast applied yesterday for her fractured ankle, Reports tingling in the right foot: Musculoskeletal injuries and in mobilization devices can cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia is an early sign of neurovascular impairment. Clients with diabetes are usually able to take the prescribed insulin dose when ill, and some clients may need a higher dose. Ellis is a physiologic stressor and can increase blood glucose level. The best step is to instruct this client to check glucose level and repeat every four hours and to reports glucose levels above or below the target range to the HCP for specific orders. This is not the most urgent call.

The nurse caring for a client in the ICU reports a critical lab value of 120,000/mm^3 platelets, decreased from 300,000mm^3 on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1. Contact the appropriate certification and licensing board 2. Document the exchange in the chart 3. Report the incident to the hospitals legal team 4. Report the incident to the state medical board

Document the exchange in the chart: There are 2 forms of heparin induced thrombocytopenia. The first form (platelets > 100,000) normalizes within a few days. The second form (platelets <40,000) is a life threatening autoimmune process that requires immediate heparin discontinuation. The nurse should document and then report objections about a clinicians judgement to the nursing supervisor.

A client was treated in the ED 2 days ago. The nurse makes a follow up call to say that a clulture shows that the client needs an antibiotic. The clients spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? 1. Call the prescription into the clients pharmacy 2. Document the spouses statement in the clients chart 3. Notify the ED physician 4. Request that the spouse tell the client to call back

Request that the spouse tell the client to call back: A competent adult with decision making capacity can refuse essential treatment; the clients spouse does not have the legal authority. Treatment refusal must include awareness of the risks and benefits

Four clients come to the ED. Which client should the triage registered nurse assign as highest priority for definitive diagnosis and treatment? 1. Client with COPD with yellow expectoration and a oxygen saturation of 91% 2. Healthy child with new onset fiery red rash on cheeks and the "flu" 3. Middle aged client with vaginal itching and white, curdlike discharge 4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face

Unconscious elderly client who smells of alcohol and has fresh vomit on the face: A client with emesis and decreased level of consciousness is a priority due to airway obstruction risk.