Leadership Management Saunders nclex review

A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? 1.Assault 2.Battery 3.Slander 4.Invasion of privacy

1 Assault Rationale:Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result from the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality

A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially? 1.Contact the client's primary health care provider (PHCP). 2.Call the client's family to arrange for transportation. 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

1.Contact the client's primary health care provider (PHCP Rationale:In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release, unless they pose an immediate danger to themselves or others, in which case the admission could become involuntary depending on the circumstances and regulations in that area and facility. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client

The registered nurse (RN) is planning her client assignments for the day. She has a licensed practical nurse and an assistive personnel (AP) on her team. Which task should the RN delegate to the AP? 1.Empty a client's urinary catheter bag. 2.Instruct a client on his or her new diabetic diet. 3.Teach a client how to check her or his blood glucose. 4.Evaluate a newly admitted client's home medications

1.Empty a client's urinary catheter bag. Rationale:The nurse must delegate tasks according to the educational level of staff members. Unlicensed personnel such as a AP can perform tasks that are noninvasive, such as emptying a urinary catheter bag. Additionally, APs are not trained to teach or evaluate. Only an RN can teach, evaluate, and instruct. Test-Taking Strategy(ies):Focus on the subject, the task to be assigned to the AP. Remember that the AP is not trained to perform invasive procedures or to teach or evaluate. Eliminate options 2 and 3 because of the words instruct and teach and option 4 because of the word evaluate. Among the tasks listed, the only one that the AP can perform is the one in option 1.

The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. 1.Flashlight 2.Supply of batteries 3.Battery-operated radio 4.Extra pair of eyeglasses 5.4-week supply of water 6.4-week supply of nonperishable food

1.Flashlight 2.Supply of batteries 3.Battery-operated radio 4.Extra pair of eyeglasses Rationale:Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day). Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and food is unnecessary and not recommended

The home health nurse develops a plan of care for the client. Which actions should the nurse include in the plan as a case manager of the client's care? 1.Organize, manage, and balance health care services needed for the client. 2.Report daily to all members of the client's health care team to advise them of the plans. 3.Plan weekly meetings with all persons involved in the care of this client to assess status. 4.Conduct daily teaching sessions for the client and significant others about the case management process.

1.Organize, manage, and balance health care services needed for the client. Rationale:The role of the case manager is to organize, manage, and balance health care services needed for the client. Although options 2, 3, and 4 may be aspects of the role of the case manager, the correct option identifies the overall role

The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)? 1.Determining if the client has consistently been medication compliant 2.Providing distraction for the client by engaging the client in a board game 3.Discussing the frequency and duration of the hallucinations with the client 4.Assisting the client in identifying any new stressors he or she may be experiencing

2.Providing distraction for the client by engaging the client in a board game Rationale:Although all of the options represent appropriate interventions, APs are permitted only to engage the client in a distraction such as a board game, and so it is an intervention that the nurse may delegate after sufficiently instructing the AP. The other options, assessing medication compliance, the characteristics of the hallucinations, and stressors, are nursing responsibilities and may not be delegated to a AP Test-Taking Strategy(ies):Note the strategic words, most appropriately. Focus on the subject, the task that can be delegated to the AP. Selecting the task that is most basic and unrelated to medical or nursing therapies will direct you to option 2

Which tasks should the registered nurse (RN) delegate to the licensed practical nurse (LPN)? Select all that apply. 1.Assessment 2.Urinary catheterization 3.Endotracheal suctioning 4.Intramuscular medication administration 5.Subcutaneous medication administration 6.Intravenous push medication administration

2.Urinary catheterization 3.Endotracheal suctioning 4.Intramuscular medication administration 5.Subcutaneous medication administration Rationale:In general, an LPN can perform the tasks that an assistive personnel can perform (skin care, range-of-motion exercises, grooming, ambulation, hygiene measures) as well as dressing changes, endotracheal suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramuscular, some piggyback medications). Assessment and administration of intravenous medications are responsibilities of the RN and outside of the scope of practice of the LPN Test-Taking Strategy(ies):Focus on the subject, delegation to an LPN. Of the functions listed, sort those that are strictly skills that do not require advanced nursing judgment from those that require professional judgment and advanced knowledge. In general, those areas of nursing practice that require professional judgment and advanced knowledge cannot be delegated

A registered nurse (RN) is observing a licensed practical nurse (LPN) preparing a client for treatment with a continuous passive motion (CPM) machine. Which action by the LPN requires follow-up by the RN? 1.The LPN keeps the client's knee at the hinged joint of the machine. 2.The LPN assesses the client for pressure areas at the knee and the groin. 3.The LPN places the client's knee in a slightly externally rotated position. 4.The LPN checks the degree of extension and flexion and the speed of the CPM machine according to the primary health care provider's (PHCP's) prescriptions

3.The LPN places the client's knee in a slightly externally rotated position. Rationale:In the use of a CPM machine, the leg should be kept in a neutral position and not rotated either internally or externally. The knee should be positioned at the hinge joint of the machine. The nurse should monitor for pressure areas at the knee and the groin and should follow the PHCP's prescriptions and institutional protocol regarding extension and flexion and the speed of the CPM machine

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1.The client receiving a heparin infusion 2.The client receiving a blood transfusion 3.The client receiving continuous oxygen at 2 L/min 4.The client recovering from Guillain-Barré syndrome 5.The client who just returned from surgery for a hip repair 6.The client on isolation for methicillin-resistant Staphylococcus aureus

3.The client receiving continuous oxygen at 2 L/min 4.The client recovering from Guillain-Barré syndrome 6.The client on isolation for methicillin-resistant Staphylococcus aureus Rationale:APs cannot be assigned to a client requiring care that is more than basic. APs do not have the education to safely care for clients requiring more than basic care. Assigning a AP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN) Test-Taking Strategy(ies):Focus on the subject, assignment to a AP. Consider the complexity of the clients' required care and whether special technology is involved in the care or if there are any individual safety precautions. Also, think about the word noninvasive when assigning clients to APs. This will assist in answering this question correctly. Although the RN is ultimately accountable for delegated care, the RN needs to safely assign the care of individuals

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? 1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found lying on the floor. 4.The client became restless and tried to get out of bed

3.The client was found lying on the floor. Rationale:The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1.The informed consent does not need to be obtained. 2.The informed consent should be obtained from the family. 3.The informed consent needs to be obtained from the client. 4.The primary health care provider will provide the informed consent

3.The informed consent needs to be obtained from the client. Rationale:Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1.A client who is ambulatory demonstrating steady gait 2.A postoperative client who has just received an opioid pain medication 3.A client scheduled for physical therapy for the first crutch-walking session 4.A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

4.A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C Rationale:The nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1.A client complaining of muscle aches, a headache, and history of seizures 2.A client who twisted her ankle when rollerblading and is requesting medication for pain 3.A client with a minor laceration on the index finger sustained while cutting an eggplant 4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Rationale:In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are the highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority

The nurse is planning the client assignments for a group of clients and has a licensed practical nurse (LPN) and an assistive personnel (AP) on the nursing team. Which client would the nurse most appropriately assign to the LPN? 1.A client with stable heart failure who has early-stage Alzheimer's disease 2.A client who is scheduled for an electrocardiogram and a chest x-ray examination 3.A client who was treated for dehydration, is weak, and needs assistance with bathing 4.A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion

4.A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion Rationale:The nurse would most appropriately assign the client with emphysema to the LPN. This client has an airway problem and has the highest priority needs among the clients presented in the options. The clients described in options 1, 2, and 3 can appropriately be cared for by the AP.

Laptop computers have been purchased by a community hospital to be used in the nursing units for documentation. The nurse educator at the hospital plans in-service educational sessions regarding the use of the computers and the new documentation system. The nurse educator anticipates some resistance to the use of the computers and should plan to best deal with this difficulty by doing what? 1.Ignoring the resistance 2.Discarding all paper-type documentation forms 3.Demanding that the nurses use the new computer system 4.Allowing the nurses extra time to work with the new computer system

4.Allowing the nurses extra time to work with the new computer system Rationale:Allowing the nurses extra time to work with the new computer system will alleviate anxiety. Ignoring the issue will not address the problem. Discarding all paper-type documentation forms may cause anxiety in the nurses, particularly if the nurses are uncomfortable with the computer system. Demanding that the nurses use the new computer system may cause resentment and resistance.

The nurse is planning client assignments for the day. Which clients can be safely assigned to assistive personnel (APs)? Select all that apply. 1.Client who is receiving chemotherapy and is in isolation 2.Client with anemia who is receiving a second unit of blood and needs assessment of vital signs 3.Client newly diagnosed with hyperthyroidism who is in need of teaching regarding medication therapy 4.Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5.Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding 6.Client who is newly admitted with shortness of breath, circumoral cyanosis, and a respiratory rate of 30 breaths per minute who requires an admission assessment

4.Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing 5.Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding Rationale:The scope of practice of APs includes measurement of vital signs and assistance with feeding, bathing, and dressing. Clients who need assessment, are receiving chemotherapy, are receiving blood, or require education need the more advanced skills of a licensed nurse. Test-Taking Strategy(ies):Focus on the subject, assignment to the AP. By definition, the role of the AP is one of support to the licensed nurse. This knowledge allows you to eliminate options 1, 2, 3, and 6 because these clients require nursing intervention by a licensed person

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1.Ignore the resistance. 2.Exert coercion on the AP. 3.Provide a positive reward system for the AP. 4.Confront the AP to encourage verbalization of feelings regarding the change.

4.Confront the AP to encourage verbalization of feelings regarding the change. Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? 1.Primary level of prevention 2.Secondary level of prevention 3.Tertiary level of prevention 4.Quaternary level of prevention

3.Tertiary level of prevention Rationale:Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis. There is no known quaternary prevention level.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? 1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 30 minutes

4.Every 30 minutes Rationale:The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family

3.Transport the victim to the operating room for surgery. Rationale:In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment

The nurse should instruct the assistive personnel (AP) to avoid the use of a straight razor for which client? 1.The postoperative client 2.The client taking warfarin 3.The client with an infection 4.The client taking acetaminophen

2.The client taking warfarin Rationale:Warfarin is an anticoagulant, which places the client at risk for bleeding. Use of a straight razor increases the risk of abrasion and bleeding because of the client's ineffective clotting capability. Postoperative status, infection, and taking acetaminophen are not affected by the choice of shaving tools

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1.Call the police. 2.Cut up the photograph and throw it away. 3.Call the nursing supervisor and report the incident. 4.Call the laboratory and ask for the name of the individual who sent the photograph.

3.Call the nursing supervisor and report the incident. Rationale:Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client? 1.Ambulate the client frequently. 2.Encourage a diet that is high in protein. 3.Remove the water pitcher from the bedside. 4.Monitor the client's temperature every 2 hours

3.Remove the water pitcher from the bedside. Rationale:The client with acute glomerulonephritis commonly experiences an excess of fluid volume and fatigue. Interventions include fluid restriction and monitoring weight, intake, and output. The diet is high in calories but low in protein. The client is placed on bed rest, or at least encouraged to rest, because there is a direct correlation between proteinuria and hematuria and increased activity levels. It is unnecessary to monitor the temperature as frequently as every 2 hours.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? 1.Immobilize the affected extremity. 2.Remove jewelry and constricting clothing from the victim. 3.Place the extremity in a position so that it is below the level of the heart. 4.Move the victim to a safe area away from the snake and encourage the victim to rest.

4.Move the victim to a safe area away from the snake and encourage the victim to rest. Rationale:In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity at the heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1.A confused older client who requires feeding 2.A client who requires turning every 2 hours 3.A client admitted with dehydration who is on strict intake and output 4.A client on 3 L of oxygen by nasal cannula and a pulse oximetry reading of 89% 5.A client who experienced a 10-beat run of ventricular tachycardia and hypotension on the previous shift 6.A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

.A confused older client who requires feeding 2.A client who requires turning every 2 hours 3.A client admitted with dehydration who is on strict intake and output 6.A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day Rationale:Activities such as turning, ambulation, maintenance of intake and output, and feeding can be delegated to the AP. Therefore, clients 1, 2, 3, and 6 can be assigned to the AP. The clients in options 4 and 5 are instable or have demonstrated recent instability and should be assigned to the registered nurse for comprehensive assessment. Test-Taking Strategy(ies):Focus on the subject, assignment to the AP. Apply knowledge of the various disease processes and client needs in each of the situations and activities that can be delegated to the AP to answer this question. Focus on the stability of the client and the invasiveness of tasks to assist in answering correctly. This will direct you to the correct options.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? 1.Contact the nursing supervisor. 2.Administer the dose prescribed. 3.Hold the medication until the PHCP can be contacted. 4.Administer the recommended dose until the PHCP can be located

1. Contact the nursing supervisor. Rationale:If the PHCP writes a prescription that requires clarification, the nurse's responsibility is to contact the PHCP. If there is no resolution regarding the prescription because the PHCP cannot be located or because the prescription remains as it was written after talking with the PHCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification

The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. Which term describing this organizational chart should the vice president employ while talking with the employees? 1.Flat 2.Vertical 3.Circular 4.Horizontal

1. flat Rationale: Organizational charts are drawings that show how the parts of an organization are linked. In "flat" organizations, authority and responsibility are delegated to the lowest operational level possible. Option 2 is incorrect because a vertical chart indicates a formal line of authority and communications. Traditionally, vertical charts indicate decision making at the upper levels of management. Option 3 indicates a concentric or circular chart, with the chief executive in the center and successive layers of authority. Option 4 refers to a horizontal, or left-to-right, chart that depicts the chief executive at the left, with lower layers of the authority to the right

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1.Actual or life-threatening concerns 2.Completing care in a reasonable time frame 3.Time constraints related to the client's needs 4.Obtaining needed supplies to care for the client

1.Actual or life-threatening concerns Rationale:Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided

The staff members working at the trauma center have characterized their nurse manager as task oriented and directive. Which leadership style does the nurse manager exhibit? 1.Autocratic 2.Situational 3.Democratic 4.Laissez-faire

1.Autocratic Rationale:The autocratic style of leadership is task oriented and directive. Situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this type of leadership allows nurses to provide input and provides an opportunity to grow professionally. The laissez-faire style allows staff to work without assistance, direction, or supervision

The nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the assistive personnel (AP)? Select all that apply. 1. Inspecting skin surfaces 2. Observing the client's behavior 3. Measuring the client's height and weight 4. Assessing the client's general appearance 5. Monitoring oral intake and urinary output

2. Observing the client's behavior 5. Monitoring oral intake and urinary output Rationale:The general survey is a review of the client's main health problems and includes assessment of vital signs, height and weight, general behavior, and appearance. The nurse can delegate some aspects, such as measuring height and weight and monitoring intake and output, to APs, but the nurse is responsible for performing the general survey, including assessment of general appearance, behavior, and skin.

The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? 1."As the manager, do you maintain control and make all decisions?" 2."As the manager, do you assume a passive, nondirective approach?" 3."As the manager, do you facilitate decision making within the group?" 4."As the manager, do you change style according to the needs of the group?"

2."As the manager, do you assume a passive, nondirective approach?" Rationale:A laissez-faire leader assumes a passive, nondirective approach. Option 1 describes an autocratic leader; this type of leader would make the decisions. Option 3 describes a democratic leader. This type of leader is a "talk with the members" type of leader who gains input and facilitates decision making by the group. Option 4 describes a situational leader; this is seen when a manager indicates that in some situations, the manager decides, but in other situations, the staff nurses decide Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject, laissez-faire leadership style. Note the words letting the staff nurses make the decisions in the question. Note the relationship of this style and the words passive, nondirective approach in the correct optio

A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths? 1."They are developed based on appropriate standards of care." 2."They are nursing care plans and use the steps of the nursing process." 3."They are developed through the collaborative efforts of members of the health care team." 4."They provide an effective way to monitor care and to reduce or control the length of hospital stay for the client."

2."They are nursing care plans and use the steps of the nursing process." Rationale:Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. All other options appropriately describe the use of a critical path

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two assistive personnel (AP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN?

2.A client scheduled for a cardiac catheterization Rationale:The RN is legally responsible for client assignments and must assign tasks according to the guidelines of Nurse Practice Act and the job description of the employing agency. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments; this is the most appropriate assignment for the LPN. The RN can work with the LPN and supervise care. The AP has been trained to care for a client on bed rest and on urine collection, provide assistance with ambulation, and perform ROM exercises. The RN would provide instructions to the AP regarding the tasks, but the tasks required for these clients are within the role description of a AP Test-Taking Strategy(ies):Note the strategic words, most appropriately. Focus on the subject, LPN assignment. Note that the question asks for the assignment to be delegated to the LPN. When asked questions related to delegation, think about the role description of the employee and the needs of the client. This will direct you to the correct option.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. 1.Complete and file an occurrence report. 2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information

2.Right-click on the entry and modify it to reflect the correct information. 3.Document the correct information and end with the nurse's signature and title. 4.Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5.Document in a nurse's note in the client's record detailing the corrected information Rationale: Electronic health records (EHR) will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error in the MAR, the nurse should follow agency policies to correct the error. In the MAR, the nurse can click on the entry (usually right-click) and modify it to reflect the corrected information. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication, to validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the EHR. An occurrence report is not necessary in this situation

A case manager is reviewing the records of the clients in the nursing unit. Which occurrence, if noted in a client's record, would the nurse identify as a positive variance? 1.A client is performing colostomy irrigations. 2.The client with a leg ulcer is demonstrating signs of wound healing. 3.A postoperative client is discharged home 1 day earlier than expected. 4.The client with diabetes mellitus is administering insulin injections appropriately.

3.A postoperative client is discharged home 1 day earlier than expected. Rationale:Variances are actual deviations or detours from the critical path. Variances are positive or negative, avoidable or unavoidable, and may be caused by a variety of factors. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path. The correct option is the only one that identifies a positive variance. Options 1, 2, and 4 demonstrate progression on a critical path, but they are not specifically associated with the definition of a positive variance

The nurse is delegating the morning hygienic care of a man to the assistive personnel (AP). In reviewing the assigned tasks, the nurse should instruct the AP to use an electric razor for which client? 1.The client with severe pain related to osteoporosis 2.The client with hypokalemia related to diuretic therapy 3.The client with thrombocytopenia related to chemotherapy 4.The client with an elevated white blood cell count related to infection

3.The client with thrombocytopenia related to chemotherapy Rationale:The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. The client with severe pain is not affected by the different choices in shaving tools. Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools Test-Taking Strategy(ies):Focus on the subject, safety and the client at risk for bleeding. Think about the differences between an electric razor and any other tools commonly used to shave a man. Next, differentiate among the concepts of thrombocytopenia, pain, hypokalemia, and an elevated white blood cell count and determine which client is at risk for bleeding. This will direct you to the client with thrombocytopenia

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

4. A client with asthma who requested a breathing treatment during the previous shift Rationale:Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1.A client scheduled to receive a blood transfusion 2.A client with bladder cancer who will be receiving chemotherapy 3.A client newly diagnosed with diabetes mellitus scheduled for discharge 4.A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

4.A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours Rationale:The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client on bed rest who requires ROM exercises. The AP is trained in this procedure. The client receiving chemotherapy and the client receiving a blood transfusion require assessment skills that only a licensed nurse can perform. The client with diabetes mellitus who is being discharged will require predischarge review of diabetic management instructions and coordination of necessary home care services Test-Taking Strategy(ies):Note the strategic words, most appropriate. Recall the principles of delegation and supervision of the work of others in answering the question. Work that is delegated to others must be consistent with the individual's level of expertise and licensure or lack of licensure. Think about the training and skills of the AP to assist in answering correctly

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1.Call the client's family to arrange for transportation. 2.Contact the client's primary health care provider (PHCP). 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment

Rationale:In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client Test-Taking Strategy(ies):Note the strategic word, initially. Noting the type of hospital admission will assist in directing you to the correct option while eliminating those that are unlikely to occur. Calling the family should be eliminated, based on the issues of client rights and confidentiality. To "persuade" a client to stay in the hospital is inappropriate. Threatening the client is inappropriate and illegal

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the coworker in the medication room until help is obtained

.3. Call the nursing supervisor. Rationale:Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? 1."Cushing's syndrome is caused by excessive amounts of cortisol." 2."Cushing's syndrome is caused by decreased amounts of aldosterone." 3."Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." 4."Cushing's syndrome is caused by decreased amounts of parathyroid hormone.

1."Cushing's syndrome is caused by excessive amounts of cortisol." Rationale:Cushing's syndrome is a condition caused by excessive amounts of cortisol. Options 2, 3, and 4 are inaccurate descriptions of this disorder Test-Taking Strategy(ies):Focus on the subject, the description of Cushing's syndrome. Recalling that this disorder relates to the adrenal glands will help to eliminate options 3 and 4. Regarding the remaining choices, think of Cushing's (up, excessive secretion) to direct you to the correct option.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1.A pregnant woman who exclaims, "My baby is not moving." 2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead

2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Rationale:Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The victim who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the victim is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation the nurse educator clarifies that what is a characteristic of case management? 1.Requires that 1 nurse take care of 1 client 2.Promotes appropriate use of hospital personnel 3.Requires a case manager who plans the care for all clients 4.Uses a team approach, but 1 nurse supervises all other employees

2.Promotes appropriate use of hospital personnel Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources; its aim is to maximize hospital revenues while providing for optimal outcomes of care. Case management manages client care by managing the client care environment. Options 1, 3, and 4 are not characteristics of case management

The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriate instruction should be given to the LPN? 1.Administer 1 more enema. 2.Stop administering the enemas. 3.Continue to administer enemas until the solution is clear. 4.Wait for 1 hour and then continue administering the enemas.

2.Stop administering the enemas. Rationale:Client preparation for a barium enema may include the administration of enemas before the test. If administering enemas until clear is prescribed on the morning of the test, enemas should be administered no more than 3 times. The continuous administration of enemas may cause fluid and electrolyte disturbances and imbalances.

The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)? 1.A client who requires teaching about an insulin pump 2.Completing an admission assessment on a newly admitted client 3.Administration of a new oral medication to a client with Alzheimer's disease 4.An assessment of a client whose pulse oximetry reading is 85% and who is having difficulty breathing

3 Rationale:Oral medication administration is within the scope of practice for an LPN. Teaching is the responsibility of the registered nurse (RN). Assessments are also done by the RN. The LPN's scope of practice is restricted to data collection Test-Taking Strategy(ies):Focus on the subject, LPN assignment. Eliminate options 2 and 4 because they relate to assessment and therefore are comparable or alike. Remember that teaching needs to be done by the RN and that the LPN can administer oral medications

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1."I will sign as a witness to your signature." 2."You will need to find a witness on your own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the nursing supervisor to seek assistance regarding your request."

4."I will call the nursing supervisor to seek assistance regarding your request." Rationale: Instructional directives (living wills) are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2."If you want to know about Carol, you need to ask her yourself." 3."Only because you're worried about a friend, I'll tell you that she is improving." 4 ."Being her friend, you know she is having a difficult time and deserves her privacy

1."I cannot discuss any client situation with you." Rationale:The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1.A client needing a bed bath 2.A client needing to ambulate 3.A client needing packed red blood cells 4.A client requiring assistance with feeding 5.A client needing to have vital signs checked 6.A client needing to use the bedside commode

1.A client needing a bed bath 2.A client needing to ambulate 4.A client requiring assistance with feeding 5.A client needing to have vital signs checked 6.A client needing to use the bedside commode Rationale:APs can perform tasks that are noninvasive. Therefore, options 1, 2, 4, 5, and 6 are tasks that the AP can perform. The client in option 3 must be cared for by the registered nurse Test-Taking Strategy(ies): Focus on the subject, the tasks that are appropriate to assign to APs. Think about the word noninvasive. This will direct you to the correct options

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? 1.Call the nursing supervisor to activate the agency disaster plan. 2.Supply the triage rooms with bottles of sterile water and normal saline. 3.Call the intensive care unit to request that nurses be sent to the emergency department. 4.Call the laundry department and ask the department to send as many warm blankets as possible to the emergency department

1.Call the nursing supervisor to activate the agency disaster plan. Rationale:In an external disaster, many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the nurse would take, the initial action would be to activate the disaster plan.

A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task can be delegated to the assistive personnel (AP)? 1.Orient the client to the hospital surroundings. 2.Instruct the client on how to apply the eye drops. 3.Listen to the client express his or her frustration or loss. 4.Review hand-washing and hygiene practices with the client

1.Orient the client to the hospital surroundings. Rationale:Orienting the client to the hospital room and surroundings is within the scope of the AP's responsibilities. Instructing on the use of eye drops, reviewing hand washing, and therapeutically listening to the client's emotions require formative evaluation to gauge client readiness. These activities are the responsibilities of the registered nurse. Teaching and assessments cannot be delegated to APs Test-Taking Strategy(ies):Focus on the subject, the task that can be delegated to the AP. Remember that teaching and assessments cannot be delegated. In addition, assessing and addressing the client's concerns are the responsibility of the licensed nurse. To answer correctly, remember that basic tasks and noninvasive tasks can be delegated to the AP

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1.A client scheduled to receive parenteral nutrition 2.A client who requires assistance with ambulation every 4 hours 3.A client scheduled for discharge who needs teaching about medications 4.A client with bladder cancer who is scheduled for a cardiac catheterization

2. A client who requires assistance with ambulation every 4 hours Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a AP would be to care for a client on bed rest who requires assistance with ambulation every 4 hours. The AP is trained in this procedure. The client receiving parenteral nutrition and the client scheduled for a cardiac catheterization require the assessment skills that a licensed nurse can perform. Teaching needs to be done by the licensed nurse. The AP does not have the education to teach a client about medications

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1.Prepare the triage rooms. 2.Activate the emergency response plan. 3.Obtain additional supplies from the central supply department. 4.Obtain additional nursing staff to assist in treating the casualties.

2.Activate the emergency response plan. Rationale:In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. 1.Provide monetary relief. 2.Provide crisis counseling. 3.Identify and train personnel. 4.Issue presidential declarations. 5.Deploy National Guard troops. 6.Handle inquiries from families

2.Provide crisis counseling. 3.Identify and train personnel. 6.Handle inquiries from families Rationale:In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families Test-Taking Strategy(ies):Focus on the subject, the role of the ARC and the role of FEMA. Noting that FEMA is a federal agency will assist in eliminating the incorrect options

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? 1."The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." 2."If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." 3."Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4."You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way

3."Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." Rationale:Option 3 describes legitimate power. Legitimate power is based on a person's position within an organization or society. The organizational leadership has mandated performance outcomes, and management has the responsibility to see that the mandate is met. Option 1 demonstrates informational power. The manager is using data to drive compliance with the mandate. Option 2 reflects an example of coercive power. Coercive power is a "do this or else" type of approach. Option 4 reflects expert power. The manager is asking the staff nurses to comply with the mandate because the manager possesses expert knowledge and skill levels. In addition to coercive, informational, expert, and legitimate power, the manager has referent, reward, and personal power Test-Taking Strategy(ies):Focus on the subject, legitimate power. Option 3 best reflects this type of power. Remember that with the authority that is delegated to management comes power, and remember that the manager must recognize the types of power available to the manager and apply them effectively. The strategy to successful management is application of the type of power most effective in meeting workplace challenges

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections 4.A client with difficulty swallowing food and fluids

3.A client who requires urine specimen collections Rationale:The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration

The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal? 1.Autocratic 2.Situational 3.Democratic 4.Laissez-faire

3.Democratic Rationale:Democratic styles empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally. The autocratic style is task oriented and directive. Situational leadership uses a style that depends on the situation and events. Laissez-faire allows staff to work without assistance, direction, or supervision

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1.The nurse who never had roseola 2.The nurse who never had mumps 3.The nurse who never had chickenpox 4.The nurse who never had German measles 5.The nurse who never received the varicella-zoster vaccine

3.The nurse who never had chickenpox 5.The nurse who never received the varicella-zoster vaccine Rationale:The nurses who have not had chickenpox or did not receive the varicella zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus or who did not receive the varicella zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster

he nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1.Using sterile sheets and linens 2.Performing strict hand-washing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

3.Wearing gloves and a gown only when giving direct care to the client Rationale:In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client. Test-Taking Strategy(ies):Note the word unsafe in the question. Options 1 and 2 can be eliminated easily because of the words sterile and strict in these options. Next, note the closed-ended word "only" in the correct option. Also, the correct option identifies the least thorough technique to prevent infection

he nurse is planning the client assignments for the shift. Which client should the nurse assign to the assistive personnel (AP)? 1.A client requiring dressing changes 2.A client requiring frequent temperature measurements 3.A client on a bowel management program requiring rectal suppositories and a daily enema 4.A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

4 Rationale:Assignment of tasks to the AP needs to be made based on job description, level of clinical competence, and state law. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse. The client described in the correct option has needs that can be met by a AP Test-Taking Strategy(ies):Focus on the subject, client assignment to a AP. Think about the tasks that the AP can safely perform and match the client's needs to these tasks. Eliminate options 1, 3, and 4 because these clients require care that needs to be provided by a licensed nurse.

he nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse? 1.Manager 2.Educator 3.Advocate 4.Caregiver

4.Caregiver Rationale:The nurse is practicing basic nursing skills. Some of the tasks can be delegated, but the nurse chose to perform them, so the nurse is acting as a caregiver. A manager coordinates the care of a client, an educator teaches a client, and an advocate upholds a client's rights

The nurse is developing a client care assignment for a group of assistive personnel (APs). What is the nurse's first step in planning and assigning clients? 1.Determine what skills can be delegated. 2.Determine the years of experience of each AP. 3.Determine how much supervision is required for each client assigned. 4.Determine how many clients the agency allows to be delegated to each AP.

1. Determine what skills can be delegated. Rationale: Knowing what skills can be delegated is essential when nurses assign client care to other health care personnel. Nurses must be familiar with their state's Nurse Practice Act, institutional policies and procedures, and the institution's job description for APs. Information from these sources is necessary to define the level of competency of APs. Determining how many clients to delegate is not the first step, and in fact most agencies do not state a specific number of clients that may be assigned. Determining years of experience is also not a first step, although a AP's experience could affect the type of client assigned. How much supervision will be required is also important but, again, not the first step the nurse takes when delegating client assignment to the APs.

The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks should be assigned to the assistive personnel (AP)? Select all that apply. 1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 p.m. vital signs on clients 4.Giving medications left by the nurse for the client to take 5.Assisting a client with a urinary drainage catheter into a chair 6.Obtaining a catheterized urinalysis and taking it to the laboratory

1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 p.m. vital signs on clients 5.Assisting a client with a urinary drainage catheter into a chair Rationale:Medication administration and invasive procedures, such as urinary catheterization for specimen collection, cannot be done by the AP; therefore, these options are incorrect. The remaining options identify activities that can be performed by the AP. Test-Taking Strategy(ies):Focus on the subject, assignments appropriate for a AP. Remember the word noninvasive when thinking about assignments for a AP. This will direct you to the correct option

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1.The acuity level of the clients 2.Specific requests from the staff 3.The clustering of the rooms on the unit 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities

1.The acuity level of the clients 5.Client needs and workers' needs and abilities Rationale:There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments

Which identifies accurate nursing documentation notations? Select all that apply. 1.The client is resting in bed with the eyes closed. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1.The client is resting in bed with the eyes closed. 2.Abdominal wound dressing is dry and intact without drainage. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Rationale:Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1.Libel 2.Battery 3.Assault 4.Slander 5.False imprisonment

2.Battery 3.Assault 5.False imprisonment Rationale:False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the client

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1.Refuse to float to the ICU based on lack of unit orientation. 2.Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. 3.Ask the nursing supervisor to review the hospital policy on floating. 4.Submit a written protest to nursing administration, and then call the hospital lawyer

2.Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. Rationale:Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action

The nurse manager has involved all staff members in the development of goals and decision making. Which leadership style has the unit manager exercised? 1.Autocratic 2.Democratic 3.Situational 4.Laissez-faire

2.Democratic Rationale:Democratic leadership is defined as participative, with a focus on the belief that all members of the group have input into the decision-making process. This leader acts as a resource and facilitator. Autocratic leadership dominates the group, with maintenance of strong control over the group. Situational leadership is based on the current events of the day. Laissez-faire leaders assume a passive approach, with the decision making left to the group

When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN? 1.A client requiring frequent temperature checks 2.A client requiring assistance with ambulation every 4 hours 3.A client on a mechanical ventilator requiring frequent assessment and suctioning 4.A client with a spinal cord injury requiring urinary catheterization every 6 hours

3.A client on a mechanical ventilator requiring frequent assessment and suctioning Rationale: When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the AP, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1.Each staff member is assigned a specific task for a group of clients. 2.A staff member is assigned to determine the client's needs at home and begin discharge planning. 3.A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). 4.An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients

4.An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients Rationale:In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice)

A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the assistive personnel (AP)? Select all that apply. 1.Collecting a urine specimen from a client 2.Obtaining frequent oral temperatures on a client 3.Accompanying a client being discharged to his or her transportation to home 4.Assisting a postcardiac catheterization client who needs to lie flat to eat lunch 5.Monitoring the amounts of fluid remaining in intravenous (IV) solution bags for a client receiving IV fluids

1.Collecting a urine specimen from a client 2.Obtaining frequent oral temperatures on a client 3.Accompanying a client being discharged to his or her transportation to home Rationale:Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. Based on the options provided, the most appropriate activities for a AP are noted in options 1, 2, and 3. These options do not include situations to indicate that these activities carry any risk. Because the client needs to eat lying flat, the client is at risk for aspiration. Care related to IV therapy needs to be done by a licensed nurse Test-Taking Strategy(ies):Note the strategic words, most appropriate, and focus on the subject, assignment to the AP. Use the ABCs-airway, breathing, and circulation-and recall the principles of delegation in answering the question.

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN? 1.Place the client in a side-lying position. 2.Initiate wound care protocol for standardized ulcer care. 3.Meet with the wound specialist to identify measures to improve healing. 4.Determine which treatments would best meet the healing needs of the client

1.Place the client in a side-lying position. Rationale:The best task for the LPN is to place the client in the side-lying position. Proper positioning requires nursing skills and is within the LPN's abilities and scope of practice. Initiating a wound care protocol, meeting with the wound specialist to identify measures to improve healing, and determining which treatments would best meet the healing needs of the client are outside the LPN's scope of practice, even though the LPN may assist the RN in determining the plan of care. These activities are the RN's responsibilities.

Which identifies accurate nursing documentation notation(s)? Select all that apply. 1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Rationale:Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? 1.Libel 2.Slander 3.Assault 4.Negligence

2. Slander Rationale:Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply. 1.Document a late entry in the client's record. 2.Draw 1 line through the error, initialing and dating it. 3.Try to erase the error for space to write in the correct data. 4.Use whiteout to delete the error to write in the correct data. 5.Write a concise statement to explain why the correction was needed. 6.Document the correct information and end with the nurse's signature and title.

2.Draw 1 line through the error, initialing and dating it. 6.Document the correct information and end with the nurse's signature and title. Rationale:If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing 1 line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary. Test-Taking Strategy(ies):Focus on the subject, correcting a documentation error, and use principles related to documentation. Recalling that alterations to a client's record are to be avoided will assist in eliminating options 3 and 4. From the remaining options, focusing on the subject of the question and using knowledge regarding the principles related to documentation will direct you to the correct option

The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply. 1. Respect assumptions. 2.Monitor language and tone. 3.Adopt a "need-to-know" policy. 4.Be alert to the presence of gossip. 5.Try to limit the use of obscene language. 6.Hold yourself and one another accountable

2.Monitor language and tone. 3.Adopt a "need-to-know" policy. 4.Be alert to the presence of gossip. 6.Hold yourself and one another accountable Rationale: Some ethical strategies to use when preparing a change-of-shift report include the following: monitoring language and tone, adopting a "need-to-know" policy, being alert to the presence of gossip, and holding oneself and one another accountable. Respecting assumptions and limiting the use of obscene language are not appropriate strategies. A change-of-shift report is given from 1 caregiver to another caregiver who is taking on responsibility for the client's care to ensure continuity of care.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms.

2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. Rationale:In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1.A middle-aged man with 1 foot trapped under the wreckage 2.A crying teenager who is holding pressure on an arm laceration 3.A young woman who appears dazed and confused and is shivering 4.A screaming middle-aged woman looking frantically for her husband

3.A young woman who appears dazed and confused and is shivering Rationale:The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival Test-Taking Strategy(ies):Note the strategic word, first. Being the only responder at the scene, the nurse can only attend to 1 client at a time. Read the description of each client, and think about survivability. Choose the client most at risk and most likely to respond to the nurse's initial action first. A client in shock can deteriorate rapidly, and quick intervention can lead to survival.

he nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 1.Fractured tibia 2.Penetrating abdominal injury 3.Bright red bleeding from a neck wound 4.Open massive head injury in deep coma

3.Bright red bleeding from a neck wound Rationale:The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of "expectant" is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last

n older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1."Oh, really? I will discuss this situation with your son." 2."Let's talk about the ways you can manage your time to prevent this from happening." 3."Do you have any friends who can help you out until you resolve these important issues with your son?" 4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay

4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay Rationale:The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1.A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours

4.A client requiring abdominal wound irrigations and dressing changes every 3 hours Rationale:When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by an AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1.Finish the bed bath and then administer the pain medication to the other client. 2.Ask the AP to find out when the last pain medication was given to the client. 3.Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4.Cover the client, raise the side rails, tell the client that the nurse will return shortly, and administer the pain medication to the other client.

4.Cover the client, raise the side rails, tell the client that the nurse will return shortly, and administer the pain medication to the other client. Rationale:The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1.Performing a procedure without consent 2.Threatening to give a client a medication 3.Telling the client that he or she cannot leave the hospital 4.Observing care provided to the client without the client's permission

4.Observing care provided to the client without the client's permission Rationale:Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment