Leadership ATI A

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 client who is in balanced skeletal traction -A client who had a total hip arthroplasty 3 days ago -A client who has a fractured femur with a new cast -A client who had a right above-the-knee amputation 24hr ago

-A client who had a right above-the-knee amputation 24hr ago A nurse from a medical unit can care for this client because the surgical dressing is usually left in place for 48 to 72 hr, so the residual limb does not require special care at this time.

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take? -Open the top flap of the sterile package towards the body -Maintain a 0.5in border around the edges of the sterile field -Pick up the first sterile glove by grasping the folded cuff edge -Remove soiled dressings using sterile gloves

-Pick up the first sterile glove by grasping the folded cuff edge The nurse should pick up the first sterile glove by grasping the folded cuff edge, which is the palmar side, to prevent contamination of the outside of the glove.

A nurse is caring for 4 clients. Which of the following assessment findings is the priority? -A client who has facial drooping following a stroke 8hrs ago -A client who has a femur fracture and reports feeling short of breath -A client who had an appendectomy 12hr ago and reports pain as 5 -A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing

-A client who has a femur fracture and reports feeling short of breath When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is a client who has a femur fracture and reports feeling short of breath. Clients who have a fracture can develop a deep-vein thrombosis, which can lead to pulmonary embolism.

A nurse in an ED 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 client who has a penetrating head injury and RR of 4 -A client who has a comminuted fracture of the femur -A client who has a 6in laceration to the scalp with clotted blood visible -A client who has a sucking chest wound

-A client who has a sucking chest wound A client who has a sucking chest wound has an immediate threat to life and requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend the provider evaluate this client first.

A nurse on a med-surg unit is caring for 4 clients. The nurse should recognize that which of the following clients is the priority? -A client who is scheduled for a tubal ligation in 2hr and is crying -A client who has peripheral vascular disease and has an absent pulse in the right foot -A client who has type 1 DM and needs the first dressing change for an ulcer -A client who has MRSA and has an axillary temp of 38 (100.4)

-A client who has peripheral vascular disease and has an absent pulse in the right foot When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is an absent pulse, which indicates no blood flow to the extremity.

A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? -A nurse is photocopying their assigned client's diagnostic test results -An AP documents a client's VS on the client's paper based graphic record -The unit secretary faxes a client's labs to the provider -An RN stays with a client who is reading the medical records that were requested

-A nurse is photocopying their assigned client's diagnostic test results Photocopying diagnostic test results is a breach of the client's confidentiality and privacy.

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? -Request crutches from a medical equipment provider -Advise the client to install grab bars in the bathroom at home -Encourage the client to allow a home care aide to perform ADLs for them -Contact hospice to provide follow up care for the client

-Advise the client to install grab bars in the bathroom at home The nurse should advise the client to install grab bars in the bathroom at home to reduce the risk for falls.

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? -Verify that the client understands the risks of the surgery -Ask the client to explain the procedure that is being performed -Answer the client's questions about the outcomes of the surgery -Determine if the client understands the benefits of the procedure

-Ask the client to explain the procedure that is being performed The nurse should ask the client to explain the procedure that is being performed. This allows the nurse to verify the client's understanding of the information provided by the provider prior to witnessing the client's signature on the consent form.

A client on a general surgical unit tells a nurse that staff members are not answering the call light promptly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first? -Notify the charge nurse of the client's request for transfer -Assure the client that their concern has been shared with the staff -Tell the client that future calls will be answered in a timely manner -Ask the client to verbalize their expectations

-Ask the client to verbalize their expectations The first action the nurse should take using the nursing process is to assess; therefore, the first action the nurse should take is to assess the client's feelings and clarify expectations.

A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first? -Assist clients who are in immediate danger to a safe location -Close doors and windows on the unit -Attempt to extinguish the fire using an ABC fire extinguisher -Discontinue oxygen use for clients who can breathe without it

-Assist clients who are in immediate danger to a safe location The greatest risk to clients is injury from the fire. Therefore, the first action the nurse should take is to move clients who are in immediate danger to a safe location.

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? -Assist in weighing the options involved in the decision -Provide a legal representative for the family -Recommend the best course of action for the client -Decide how the nursing team should resolve the dilemma

-Assist in weighing the options involved in the decision Ethics committees are members of the interprofessional team who assist with problem solving related to ethical dilemmas. The ethics committee examines all of the facts and provides support for the clients and caregivers.

A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching? -Change of shift report can be given at the client's bedside -I can provide client information over the phone if the caller identifies themselves as family -A client cannot see their medical record because it is considered to be property of the facility -Access to client information is limited to direct care providers

-Change of shift report can be given at the client's bedside Change-of-shift report is often given at the client's bedside to help protect the client's privacy. This allows the client to be involved with their care. The nurse should avoid giving report in public areas, such as in the hallway.

Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an AP? -Take VS q2h for the client who had a cholecystectomy in room 6122 -Check the urinary output at 1100 for john doe and report it to me immediately -Report to me if the chest tube drainage is excessive for jane doe in room 2438 -Please notify me of any clients whose VS or blood glucose levels are significant

-Check the urinary output at 1100 for john doe and report it to me immediately This instruction follows the Five Rights of Delegation by including the requirements for right direction/communication: the data to collect, client-specific information, a timeline for collection, and the expectation for communicating the findings back to the nurse.

A client who has back pain presents to an ED and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make? -It sounds like nonpharmacological interventions would be best for this client -Let's withhold the oxycodone until we can consult with the provider -Contact mental health services to arrange for a consultation -Clients are the experts on their own pain

-Clients are the experts on their own pain This response is appropriate because it indicates the nurse understands that the client's report is the best indicator of pain and is not making any assumptions.

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 nurse can provide basic treatment information to the client's employer -A nurse can inform the client about the risks and benefits of electroconvulsive therapy -Clients on a mental health unit who are admitted voluntarily cannot leave against medical advice -Clients on a mental health unit can refuse their medication

-Clients on a mental health unit can refuse their medication Regardless of the type of health care facility or admission status, clients maintain the right to refuse medications.

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a LTC facility. Which of the following actions should the team take to evaluate the effectiveness of the plan? -Compare data from clients' records regarding skin integrity with established criteria -Measure staff attendance at an educational program on managing pressure injuries -Interview clients regarding their satisfaction with their care -Monitor use of supplies used to prevent pressure injuries

-Compare data from clients' records regarding skin integrity with established criteria Chart audits are an efficient and accurate way to measure if a change in a performance improvement indicator has occurred after an intervention is implemented.

A nurse is assigning care for 4 clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel? -Instruct a client how to take their BP -Administer subcutaneous medications to a client -Determine a client's I/O -Provide a status update to a client's family member

-Determine a client's I/O The nurse can delegate determining a client's intake and output to an AP, as this does not require the use of the nursing process and is within the range of function of an AP.

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next? -Set target dates for completion -Identify areas of support -Determine goals and objectives Implement recommended strategies

-Determine goals and objectives According to evidence-based practice, the nurse attempting to make a change or revision to a policy should first develop the initial plan and then determine goals and objectives. Objectives define strategies or implementation steps to attain the identified goals.

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? -Inform the client of the consequences of decreased cerebral circulation -Initiate a mental health consultation to determine why the client refuses the surgery -Discuss the client's concerns about having the surgery -Provide the client with information on additional treatment options

-Discuss the client's concerns about having the surgery The nurse should ask the client relevant questions to determine their concerns regarding having the surgery. By asking relevant, open-ended questions, the nurse can help the client clarify their thoughts and feelings about the surgery. The nurse can then relay these concerns to the provider for further discussion if needed.

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 information about alternate birth control methods -Ask if the client has discussed the decision with their partner -Emphasize the benefits of having the procedure -Discuss the client's feelings about the procedure

-Discuss the client's feelings about the procedure The nurse should encourage the client to discuss any feelings or concerns about the procedure.

2 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 in which of the following ways? -Schedule the nurses to work on alternating shift -Organize a task force to evaluate the situation -Tell the nurses that it is their responsibility to cooperate with coworkers -Explore alternative solutions to address unit workflow with the nurses

-Explore alternative solutions to address unit workflow with the nurses Exploring alternative solutions will allow the nurses to collaborate, which creates a higher probability that the nurses will reach a successful resolution.

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? -Write a memorandum emphasizing the importance of attending staff meetings -Appoint a task force to promote attendance at the meetings -Explore the reasons that staff are not attending the meetings -Reduce the number of meetings the staff are required to attend

-Explore the reasons that staff are not attending the meetings According to evidence-based practice, the nurse should first identify the reasons that staff are not attending the meetings. This allows the nurse to address the specific problems identified by the staff.

A nurse is caring for a client who requests pain medication. The nurse fulfills a promise to return with the medication within 15 minutes. The nurse is demonstrating which of the following ethical principles? -Beneficence -Utility -Justice -Fidelity

-Fidelity The nurse is demonstrating fidelity by returning to the client's room with the medication in a timely manner. Fidelity is an ethical principle in which the nurse's actions are taken to display loyalty and keep a promise made to the client.

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? -Spends free time conversing with other staff at the nurse's station -Frequent use of restroom -Asks other nurses to administer pain medication for their clients -Delegated tasks to assistive personnel

-Frequent use of restroom Frequent use of the restroom can indicate that the nurse might be working while impaired. Other indications can include frequent errors, mood swings, inability to focus, and excessive wasting of controlled substances.

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? -Documents client tasks at the end of the shift -Gathers supplies as needed while completing an activity -Groups tasks that are in the same location -Skips breaks throughout the day to complete work on time

-Groups tasks that are in the same location The newly licensed nurse should group tasks that are in the same location to effectively use time. This prevents the nurse from going back and forth from one area to another. This action promotes effective time-management skills.

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? -Child protective services -Public health -Home health -Women, infants, and children

-Home health A home health agency can provide nurses who will visit the home and help the guardian learn necessary skills, as well as assess the progress of the infant.

An AP tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent. Which of the following responses should the charge nurse make? -I delegate tasks to personnel based on their job descriptions -Everyone working here has to care for clients who are incontinent -Let's talk about organizing the workflow so you care for fewer of these clients -Why do you not want to care for clients who are incontinent

-I delegate tasks to personnel based on their job descriptions This response addresses the AP's concerns and provides clear information about the charge nurse's responsibility when delegating tasks.

A nurse is caring for a 19yo client 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? -I will have the provider discuss treatment options with your parents -I will gather information about palliative care for you -I will contact your spiritual advisor to discuss this decision with you -I will contact your parents about becoming your designees in your durable power of attorney

-I will gather information about palliative care for you The nurse is acknowledging the client's right to refuse treatment and is demonstrating support by offering to discuss end-of-life care options.

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 a charge nurse on the PACU take? -Take extra wheelchairs to the ED -Send PACU assistive personnel to assist with triage -Identify stable clients for transfer to a surgical unit -Report to the command center for further instructions

-Identify stable clients for transfer to a surgical unit It is within the charge nurse's scope of practice to identify stable clients for transfer to a surgical unit. This action will enable the facility to do the most good for the greatest number of clients.

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? -Assess the client's incision q8h for the first 48 hr -Inform the assistive personnel of the client's weight-bearing status -Instruct the client to cross their legs at the ankles when sitting in a chair -Teach the client's partner to assist the client to flex the hip at least 120 degrees every hour

-Inform the assistive personnel of the client's weight-bearing status Assistive personnel can assist clients with ambulation in most cases with appropriate delegation from the nurse. The nurse should inform the AP of postoperative prescriptions for weight-bearing as part of safe care delegation.

A nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "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? -Leave the medication on the client's bedside table to take later -Return in 1hr to administer the medication -Mix the medication in applesauce to administer to the client -Inform the client of the consequences of refusing the medication

-Inform the client of the consequences of refusing the medication The nurse should inform the client of the consequences of refusing the medication. It is the client's right to decide whether to take the medication. If the client still refuses after receiving further information, the nurse should waste the medication and document the occurrence in the client's medical record.

A nurse manager needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing this issue? -Inform the staff of the penalties that can result from medication errors -Encourage the staff to have 2 nurses verify medication orders to prevent errors -Provide a suggestion box for the staff to submit ideas for error prevention -Ask 3 experienced nurses to help investigate common causes of the errors

-Inform the staff of the penalties that can result from medication errors The nurse manager is using penalties to promote behavior change; this is characteristic of authoritarian leadership.

A nurse is providing pre-op teaching for a client who is scheduled for a total knee arthroplasty and speaks a different language than the nurse. Which of the following interprofessional team members should the nurse include in the discussion? -Interpreter -Social worker -Occupational therapist -Spiritual advisor

-Interpreter The nurse should plan to request an interpreter for the client. The role of the interpreter is to interpret between the language spoken by the client and the language spoken by the nurse.

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? -Report the findings to the hospital ethics committee -Alert central supply -Fill out an incident report -Notify the quality improvement team

-Notify the quality improvement team The nurse should report any unusual occurrences or trends, such as VAP within the unit, to the quality improvement team. The quality improvement team will analyze and evaluate the data to implement needed changes.

A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hr. The nurse Should identify that which of the following assessments is the priority? -Auscultate the client's bowel sounds -Measure the client's temperature -Check the client's urine specific gravity -Obtain the client's serum potassium level

-Obtain the client's serum potassium level Because vomiting and diarrhea contribute to the loss of potassium through body fluids, the greatest risk to this client is life-threatening cardiac dysrhythmias as a result of hypokalemia; therefore, the nurse should identify that the priority assessment is the client's 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? -Podiatrist -Social worker -Paramedical technologist -Occupational therapist

-Occupational therapist The nurse should recommend a referral to an occupational therapist for a client who has osteoarthritis and reports difficulty with ADLs, such as buttoning clothing. Occupational therapy can assist the client with exercises to help the client complete these tasks.

A nurse manager finds that there has been an increase in UTIs on the unit. To address this problem, which of the following actions should the nurse manager take first? -Conduct an in-service that reviews proper catheter insertion and maintenance -Perform a chart review to gather data about the clients who developed infections -Observe each staff nurse perform a catheter insertion -Require completion of a self-paced instruction program

-Perform a chart review to gather data about the clients who developed infections The first action the nurse manager should take when using the nursing process is to assess. The nurse should conduct a chart audit to gain important information about the factors responsible for the increased incidences of infection.

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? -Assign 2 clients who have had a stem cell transplant to the same room -Obtain a rectal temperature on clients q4h -Wear an N95 respirator mask while caring for these clients -Place clients in positive pressure airflow rooms

-Place clients in positive pressure airflow rooms The nurse should place a client who requires protective environment precautions following a stem cell transplant in a private, positive-pressure airflow room. The room air is filtered through a HEPA filter and the airflow rate is set at more than 12 air exchanges each hour.

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 newly licensed nurse to take? -Place the client in a dorsal recumbent position for the examination -Auscultate for vascular bruits with the diaphragm of the stethoscope -Begin the assessment by using light palpation over the abdomen -Ensure that the client has a full bladder before beginning the procedure

-Place the client in a dorsal recumbent position for the examination To prepare the client for a routine abdominal assessment, the nurse should place the client in a dorsal recumbent or supine position and ensure that the client relaxes her abdominal muscles.

A home health nurse is planning her daily visits and receives labs for 4 clients. The nurse should first visit the client who has which of the following labs? -Digoxin 1.0 ng/mL -WBC 6,000 -Platelets 100,000 -Serum potassium 4.0

-Platelets 100,000 A client who has a platelet count of 100,000/mm3 is unstable because this value is below the expected reference range of 150,000 to 400,000/mm3, which places the client at risk for bleeding; therefore, the nurse should visit this client first.

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a LPN? -Determine the swallowing ability of a client who has had a stroke -Provide an enteral feeding to a client who has Crohn's disease -Develop a teaching plan for a client who has a new diagnosis of type 2 DM -Weigh a client who is 3 days postop following coronary artery bypass grafting

-Provide an enteral feeding to a client who has Crohn's disease Administration of an enteral feeding is within the scope of practice of an LPN; therefore, it is appropriate for the charge nurse to assign this task to an LPN.

A hospice nurse is planning care for a client who does not have advanced directives. Which of the following interventions should the nurse include in the plan of care? -Provide the client with information about advance directives -Encourage the client to contact an attorney to create advance directives -Inform the client that they will need a relative to witness their advance directives -Tell the client that The Joint Commission requires clients to have advance directives

-Provide the client with information about advance directives Health care providers must offer information to clients regarding their rights to make decisions about their care.

A nurse is reviewing safe use of a wheelchair with a group of assistive personnel. Which of the following instructions should the nurse include? -Raise the footplates of the wheelchair before transferring the client -Lock the brake on 1 wheel of the chair when transferring the client -Push the wheelchair into the elevator with the front wheels first -Stand behind the wheelchair when moving a client down a ramp

-Raise the footplates of the wheelchair before transferring the client The nurse should raise the footplates of the wheelchair before transferring the client to prevent injury.

A nurse in a med-surg 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? -Removal of staples from a surgical wound -Providing a sputum specimen -Receiving moderate sedation -Collection of a blood specimen for ABGs

-Receiving moderate sedation The nurse should verify that the client has given informed consent prior to receiving moderate sedation because this involves anesthesia.

A nurse walks into the nurses' station and sees several staff members looking at the EMR for a celebrity client on another unit. Which of the following actions should the nurse take first? -Remind the staff members that this is a breach of confidentiality -Discuss the issue with the nurse manager -Request that an administrative restriction be placed on the client's record access -Prepare a memo for the facility ethics committee

-Remind the staff members that this is a breach of confidentiality When using the urgent vs nonurgent approach to client care, the nurse determines that the first action is to intervene immediately to prevent any further breach in confidentiality.

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? -Insert the tube and begin feedings per the family's request -Ask the provider to discuss the issue with the family -Report the dilemma to the facility's dietitian -Review the client's request with the family

-Review the client's request with the family The client's living will states that artificial enteral feedings should not be allowed, and the nurse should review the client's request with the family. Staff members should use the client's living will as the guide for treatment unless a durable power of attorney for health care has been created.

A nurse asks a newly hired assistive personnel to remove a client's indwelling catheter. Which of the following actions should the nurse take to ensure they are qualified to perform this task? -Show them how to remove an indwelling catheter -Review their skill competency checklist -Ask them if they know how to remove an indwelling catheter -Pair the newly hired AP with an experienced AP

-Review their skill competency checklist A review of the AP's checklist should validate that they have demonstrated the ability to safely perform the procedure.

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 actions should the charge nurse take? -Role model a positive approach to the changes -Redirect the conversation when staff members make negative comments about the changes -Encourage staff members who support the changes to discuss the issue with resistant staff -Suggest that resistant staff members transfer to a different unit -Reprimand staff members who are resistant to the changes

-Role model a positive approach to the changes - It is important for the charge nurse to role model positive behaviors and demonstrate support of the change. - Encourage staff members who support the changes to discuss the issue with resistant staff - Peers can serve as change agents and encourage others to embrace the changes.

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert PICCS in the ICU. Which of the following resources should the nurse consult in planning for this policy? -National League for Nursing -American Academy of Nursing -Agency for healthcare research and quality -State nursing practice act

-State nursing practice act

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? -The child has red fissures at the corners of the mouth -The child has several small bruises on both legs -The child sleeps for about 13 hrs each night -The child is not regularly attending school

-The child has red fissures at the corners of the mouth Using Maslow's hierarchy of needs, the nurse should determine that the priority finding is red fissures at the corners of the child's mouth. This can indicate a vitamin B deficiency, which is a physiological need.

A case manager is planning an interprofessional conference for a client who is 3 days post-op following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference? -The client does not have transportation for discharge home -The client refuses to attend physical therapy sessions -The client's home health nurse has not completed the home assessment -The client describes feelings of depression after family visits

-The client refuses to attend physical therapy sessions The greatest risk to this client is postoperative complications due to immobility, such as atelectasis or pneumonia; therefore, the priority for discussion is the client's refusal to participate in physical therapy.

A nurse is receiving report from the assistive personnel assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first? -The client who had abdominal surgery 3 days ago is reporting feeling constipated -The client who had the hip replacement reports pain as 4 -The client who had an indwelling catheter removed 8hr ago reports an inability to void -The client who is scheduled for discharge today states they are ready to sign their paperwork

-The client who had an indwelling catheter removed 8hr ago reports an inability to void Not voiding for 6 to 8 hr after indwelling urinary catheter removal indicates this client is at risk for urinary retention, which can cause a urinary tract infection. Overdistention of the bladder can cause damage to the mucosa. Therefore, the nurse should assess this client first and report findings to the provider.

A nurse is caring for a client who is 3 days postop following open heart surgery and will be transferred to the med-surg unit. Which of the following info should the nurse plan to include in the verbal report? -The client's dressing change schedule -The client's LOC -The client's VS from previous shift -The clients occupation

-The client's LOC The nurse should include objective data regarding the client's current consciousness status in the verbal report.

A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care? -The age of the client -The availability of community support groups -The length of the client's stay -The type of insurance the client carries

-The length of the client's stay The client's clinical pathway is a standardized approach to assist the nurse to provide cost-effective client care and shorten the length of stay.

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? -The nurse places the sterile package with the top flap opening away from the body -The nurse pinches the flap on the inside of the package first to open it -The nurse reaches over the package to open the left flap -The nurse pulls the last flap of the top package away from the body

-The nurse places the sterile package with the top flap opening away from the body The nurse should place the sterile package on a flat surface so that the top flap opens away from the body. This prevents the contents of the sterile package from becoming contaminated.

A nurse is conducting an orientation class for new clients and their families at a LTC facility. Which of the following client rights should the nurse address at the orientation? -The right to be treated with respect and dignity -The right to full access of the facility -The right to refuse their medications -The right to leave regardless of provider recommendations -The right to be fully informed of their health conditions

-The right to be treated with respect and dignity -The right to refuse their medications -The right to leave regardless of provider recommendations -The right to be fully informed of their health conditions

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 urinary catheter. Which of the following responses should the nurse make? -Procedures prescribed by the provider do not require consent -This is a procedure that does not require written informed consent -You are right. I will discuss this issue with the charge nurse -Would you mind signing the informed consent form for the procedure at this time?

-This is a procedure that does not require written informed consent The client does not need to sign an informed consent form for insertion of an indwelling urinary catheter. The client gives implied consent by complying with the procedure.

A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary TB. The charge nurse should expect the newly licensed nurse to take which of the following actions? -Place the client on droplet precautions -Place the client in a room with positive-pressure airflow -Wear a surgical mask when taking the client out of the room -Wear an N95 mask when in the client's room

-Wear an N95 mask when in the client's room The nurse should wear an N95 respirator mask when caring for clients who have suspected pulmonary tuberculosis.

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 social worker will address your concerns after discharge -You should plan to go to a skilled nursing facility after discharge -Your case manager will coordinate the resources you will need -You will need hospice care until you feel stronger

-Your case manager will coordinate the resources you will need A case manager coordinates a client's care, including resources for home care.

A nurse on a med-surg 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. place these in order - terminate nurse's employment - schedule meeting with nurse - provide written reprimand - temporarily remove nurse from scheduled shifts

The first step of the progressive discipline process is counseling the employee. The manager should set up a meeting with the nurse to ensure the nurse understands the expectations of the position. The manager should explain what the nurse must do to correct the behavior. If it continues, the manager should proceed to a written reprimand, which the manager and the nurse must sign to acknowledge that they discussed the issue. If the nurse's performance still does not improve, the manager should proceed with suspension. If the problem continues, the manager should terminate the nurse's employment.