Leadership sum 24

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

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

A charge nurse is discussing disaster response with nursing staff. Which of the following statements indicates an understanding of the Hospital Incident Command System (HICS)? - "HICS ensures that necessary antibiotics and antidotes are available." - "HICS is focused on having multidisciplinary responders available." - "HICS identifies facility responsibilities and channels of reporting." - "HICS provides additional responders when needs exceed the ability of local or state agencies."

- "HICS identifies facility responsibilities and channels of reporting." R: HICS identifies responsibilities and channels of reporting within the facility to provide a uniform response plan among facilities.

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make? - "It is time to sign the consent so your treatment can begin." - "I would not have this type of surgery if I were you." - "Have you discussed other treatments with your provider?" - "I can inform the surgeon you do not want the surgery."

- "Have you discussed other treatments with your provider?" R: The nurse should seek clarification to determine what the client may or may not know about alternatives to the surgical procedure. The nurse should notify the provider about the need to discuss alternatives to surgery if necessary. Informed consent requires that the client is aware of the limitations and alternatives to the procedure.

A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP indicates a need for assistance in establishing priorities? - "I have my assignment and will start with room 1, then work my way to room 10." - "I will give this client his meal tray first, as he is going early to physical therapy." - "After breakfast, I will pack the belongings of clients who will be discharged this morning." - "I will start by providing partial baths before breakfast."

- "I have my assignment and will start with room 1, then work my way to room 10." R: The APs statement does not include consideration of the tasks that need to be performed for each client, any time restrictions, or equipment to be organized.

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

- "I should expect the hospice team to help me manage my dyspnea." R: The primary purpose of hospice care is to provide relief of symptoms related to terminal illness. It's available to clients with less than 6 months to live and does NOT include curative treatment.

A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse? - "Let's talk about something else." - "Whether or not I am a good lover is irrelevant." - "Speaking to me like that makes me uncomfortable." - "You need to lower your voice. Others can hear you."

- "Speaking to me like that makes me uncomfortable." R: This assertive response makes it clear that this type of sexually-oriented conversation and physical contact is undesired by the nurse.

A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate? - "Tell me why you feel hopeless." - "I am sure these feelings will pass once you go home." - "If I were you, I would ask for a referral to hospice care." - "Tell me what you understand about your illness."

- "Tell me what you understand about your illness." R: The nurse should use this statement to encourage the client to express her feelings and concerns.

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

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

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

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

A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first? - A client who is a 1 day postpartum after a late term miscarriage - A client who had a bilateral tubal ligation 12 hr previously - A client who is 4 days postpartum and has mastitis - A client admitted 1 hr ago for an ectopic pregnancy

- A client admitted 1 hr ago for an ectopic pregnancy R: A client who has an ectopic pregnancy is unstable. The client is at risk for rupture of the fallopian tube, hemorrhage, and shock. Nursing care requires frequent monitoring every 15 min, IV access for fluid resuscitation. The client may also require blood transfusions, oxygen, and pain management. Therefore this client is the highest priority.

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first? - A client who needs assistance with a bath - A client requesting a referral for home health services - A client asking about his PCA pump that contains morphine - A client who has questions about his new prescription

- A client asking about his PCA pump that contains morphine R: Clients who are administered morphine are at risk for respiratory distress. When using the urgent vs. nonurgent approach to client care, this is the client the nurse should care for first.

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? - A client who has diarrhea and requests clear liquids for breakfast - A client who has a cast on the left leg and reports numbness and paresthesia - A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 - A client who has pneumonia and has an axillary temperature of 38° C (101° F)

- A client who has a cast on the left leg and reports numbness and paresthesia R: The client who has a cast is at risk for acute compartment syndrome (ACS). Numbness and paresthesia are manifestations of ACS; therefore, when using the airway, breathing, circulation (ABC) approach to client care, the nurse should care for this client first.

A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? - A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight - A client who has terminal cancer and needs assistance with pain management - A client who is recovering from a stroke and needs someone to provide care while his spouse is at work - A client who has dementia and needs help with activities of daily living

- A client who has terminal cancer and needs assistance with pain management R: A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea.

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority? - A client who has a prescription for insulin and his pre-meal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/mL - A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous - A client who reports pain as 4 on a scale of to 10 at 0800 now reports pain as 6 - A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

- A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg R: A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20 points is significant. This client is unstable; therefore, this client is the nurses priority.

The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? - An adolescent female client who is belligerent and has slurred speech - A toddler who has a laceration on his forehead and is screaming - A middle adult male who is diaphoretic and reports epigastric pain - A young adult with a painful sunburn of his face and arms

- A middle adult male who is diaphoretic and reports epigastric pain R: When using the urgent vs. nonurgent approach to client care, the nurse should determine that caring for this client is the highest priority because diaphoresis and epigastric pain are manifestations of an acute myocardial infarction.

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? - A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min - A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge - A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough - An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication

- A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough R: A client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough is unstable and requires immediate medical attention; therefore, this client is the priority and the nurse should have the provider care for this client first.

Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge? - A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy - An adolescent client who was admitted 24 hr ago due to a spontaneous pneumothorax - A middle adult who is 36 hr postoperative from an open laminectomy - An older adult client who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32

- A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy R: A client who is scheduled for an elective surgery is medically stable and is not bedridden; therefore, the nurse should recommend this client for discharge.

A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.) SATA - Accompany a client who has depression to occupational therapy. - Assess a client who has hypomania for exhaustion. - Check the position of a client in soft wrist restraints. - Set limits with a client who has mania. - Sit with a client who has alcohol use disorder and whose last drink was five days ago.

- Accompany a client who has depression to occupational therapy. - Check the position of a client in soft wrist restraints. - Sit with a client who has alcohol use disorder and whose last drink was five days ago. R:

A charge nurse is providing an inservice for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment? - Ask each nurse to read the procedure and sign a form acknowledging competency. - Allow time during the workday when each nurse can demonstrate proficiency. - Require each nurse to take a written examination about the new equipment. - Verbally question the staff about the new equipment.

- Allow time during the workday when each nurse can demonstrate proficiency. R: According to evidenced-based practice, the best action to evaluate competency with a psychomotor skill is by return demonstration. Ensuring that each nurse knows how to use the equipment through return demonstration is the best way to measure correct use of the new equipment. Prior to full implementation of any new equipment, the supervisory team should allow time for training and proficiency checks to ensure that client care is not compromised.

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following? - An expert nurse provides testimony that the nurse should have handled the situation differently. - Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. - The client's attorney states that injury to the client could have been prevented. - The client's provider testifies the nurse was at fault for the injury.

- Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. R: The definition of negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent person who has similar background and experience would do. Another staff nurse who has similar background is the correct person to provide testimony.

A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report? - Situation - Background - Assessment - Recommendation

- Assessment R: The nurse should include his assessments in this level of the report. For example, the client's oxygen saturation level and the client's apical heart rate. The nurse can also include the amount of vaginal bleeding and the appearance of the wound dressing.

A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)? - Developing the plan of care for a client who has an amputation - Evaluating the outcomes of a new postoperative client - Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus - Assisting a client with crutch walking following knee replacement surgery

- Assisting a client with crutch walking following knee replacement surgery R: Assisting a client with crutch walking is within the LPN's scope of practice.

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? - Veracity - Autonomy - Fidelity - Justice

- Autonomy R: A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?

A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? - Assault - False imprisonment - Negligence - Battery

- Battery R: Battery is physical contact without the client's consent. Administering a medication against a client's wishes is an example of battery.

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? - Call the emergency response team. - Seek immediate help from the risk manager. - Call the provider for a stat DNR order. - Respect the family's wishes and do nothing.

- Call the emergency response team. R: Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility's protocol for enacting the emergency

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) SATA - Raise all side rails on the client's bed. - Obtain a prescription to restrain the client PRN. - Check on the client hourly. - Instruct the client in the use of the call light. - Apply an ambulation alarm to the clients leg.

- Check on the client hourly. - Instruct the client in the use of the call light. - Apply an ambulation alarm to the clients leg.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? - Check the client's medical record for the provider's prescription. - Explain to the client that the provider prescribed the procedure. - Assure the client that enemas are commonly prescribed for constipation. - Inform the charge nurse that the client refused the enema.

- Check the client's medical record for the provider's prescription. R: The nurse should use the client's medical record to verify the provider prescribed an enema for the client.

A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first? - Collect a stool sample for ova and parasites from a school-age child - Engage a toddler in play. - Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma. - Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.

- Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate. R: The infant who is postoperative from a surgical correction of a cleft palate is at risk for damage to the suture line and an elbow immobilizer decreases the risk of this complication; therefore, this is the task the AP should perform first.

A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take? - Verify the APs educational preparation prior to delegating the task. - Determine the time frame the AP should report the results. - Observe the AP as she obtains the vital signs of each client. - Ask the AP to take the vital signs of the client returning from a surgery first.

- Determine the time frame the AP should report the results. R: The right communication is one of the five rights of delegation. The nurse should communicate with the AP and provide direction as to when the AP should report the findings of the vital signs.

A nurse manager has received information from the facility's risk management department that a former client is pursuing a lawsuit. The nurse manager should anticipate a deposition will be required during which phase of the legal process? - Compliant phase - Discovery phase - Decision phase - Trial phase

- Discovery phase R: During the discovery phase, both attorneys for the plaintiff and the defendant obtain relevant information about the case. This includes witnesses' depositions.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? - Assessing the current health status of the client - Explaining the operative procedure, risks, and benefits - Reviewing preoperative laboratory test results - Ensuring that a signed surgical consent form was completed.

- Explaining the operative procedure, risks, and benefits. R: Explaining the procedure and any risks that may be associated with it is the responsibility of the person performing the procedure. This is not a nursing responsibility.

A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate? - You should think about how you make others feel when you lose your temper. - I will help you with this procedure instead of the staff nurse. - It must be very frustrating when you don't have what you need to perform the procedure. - If you let us know ahead of time that you plan to perform a procedure, we could do a better job of having the supplies available.

- It must be very frustrating when you don't have what you need to perform the procedure. R: The charge nurse is acknowledging the provider's frustration when making this statement. This can lead to resolution of the conflict.

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)? - Application of antibiotic ointment to the arm of a client who has dermatitis - Obtaining medical history information from a stable client who is being admitted - Monitoring vital signs of a client who had an appendectomy 12 hr ago - Removal of the nasogastric tube of a client who has been receiving enteral feedings

- Monitoring vital signs of a client who had an appendectomy 12 hr ago R: Delegating the monitoring of vital signs of a stable client 12 hr after surgery is an appropriate task for the AP because it does not involve assessment, specialized knowledge, or judgment.

A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first? - Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. - Apply a condom catheter to a client who is incontinent. - Feed a client who has bilateral casts due to upper arm fractures. - Deliver a clean voided urine specimen to the laboratory.

- Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. R: A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?

a nurse is planning to delegate a task to an assistive personnel. which of the following actions should the nurse plan to take? - Assess the AP's ability to follow the client's teaching plan - Determine the social skills of the AP. - Evaluate the ability of the AP to work with peers. - Provide a clear description of the task to the AP.

- Provide a clear description of the task to the AP. R: Providing a clear, concise description of the task, as well as the expected outcome, is essential when planning to delegate a task to the AP.

A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.) SATA - Provide discharge instructions to a confused client's spouse. - Administer a tap-water enema to a client who is preoperative. - Initiate a plan of care for a client who is postoperative from an appendectomy. - Obtain vital signs from a client who is 6 hr postoperative. - Catheterize a client who has not voided in 8 hr.

- Provide discharge instructions to a confused client's spouse. - Administer a tap-water enema to a client who is preoperative. - Initiate a plan of care for a client who is postoperative from an appendectomy.

A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit? - Availability of resources, such as fire extinguishers - Nursing staff ratios - Quality of nursing care provided - Length of facility stay for a cohort of clients

- Quality of nursing care provided. R: Process audits evaluate the quality of care nurses provide. They also determine if the care provided by nurses is consistent with established facility policy.

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

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

An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating? - Agency policies for the LPN - The documented experience level of the LPN - The documented skill level of the LPN - State Nurse Practice Act for the LPN

- State Nurse Practice Act for the LPN R: According to evidence-based practice, the nurse should first consider the state Nurse Practice Act for the LPN. This act guides agency policies and provides the legal authority for nursing practice, including delegation.

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? - Take an arterial blood gas (ABG) specimen to the laboratory. - Transport a client to the radiology department for an x-ray. - Pass fresh water to clients on the unit. - Obtain a routine urine sample from a newly-admitted client.

- Take an arterial blood gas (ABG) specimen to the laboratory. R: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate.

A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first? - Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately. - Report the behavior to the nurse manager. - Create a written document of the incident and store the document in a safe place. - Seek help from a trustworthy friend.

- Tell the hiring manager in clear terms that this conduct causes feelings of discomfort and that the behavior should stop immediately. R: Sexual harassment is unwanted sexual advances made in the context of a relationship of unequal power or authority. It is experienced as offensive in nature. The nurse should first start by taking the most direct measure: confronting the hiring manager and insisting the harassment stop.

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

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

A nurse on a medical-surgical unit is reconciling a newly admitted client's medication. The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information? - The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation. - The purpose of medication reconciliation is to prevent adverse medication reactions. - The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity. - The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility.

- The purpose of medication reconciliation is to prevent adverse medication reactions. R: Medication reconciliation includes reviewing an accurate list of all medications the client is taking and comparing that list to new medications the provider has prescribed. This action decreases the risk of medication interactions and adverse outcomes.

A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take? (Select all that apply.) SATA - Verify the client understands the surgical procedure. - Validate the signature is authentic. - Establish that the client is able to pay for the surgical procedure. - Confirm that the consent is voluntary. - Explain the surgical procedure to the client.

- Verify the client understands the surgical procedure. - Validate the signature is authentic. - Confirm that the consent is voluntary. R: Establish that the client is able to pay for the surgical procedure is incorrect. The client's ability to pay for the procedure is not required prior to obtaining an informed consent.Explain the surgical procedure to the client is incorrect. It is the surgeon's responsibility to explain the procedure to the client.Validate the signature is authentic is correct. The nurse must validate the signature on the consent is made by the client or the client's legal guardian.Verify that the client understands the surgical procedure is correct. The nurse should verify the client understands the procedure and the risks.Confirm that the consent is voluntary is correct. The nurse should confirm the client is giving voluntary consent without coercion.

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? - Complete an incident report - Request the risk manager obtain consent for HIV testing from the client. - Wash the site of injury with soap and water - Consent to post exposure treatment with antiretroviral medications

- Wash the site of injury with soap and water R: The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) - Pull the alarm - Rescue the clients - Extinguish the fire - Confine the fire

1. Rescue the clients. 2. Pull the alarm. 3. Confine the fire. 4. Extinguish the fire. R: Following the RACE mnemonic the nurse should first rescue all clients by moving them to a safe area out of immediate danger. Next the nurse should pull the alarm fire and then, if possible, call the agencies emergency extension to report the location and details of the fire. The next step the nurse should take is to close all of the room doors and fire doors at the entrance to the unit to confine the fire. Lastly, the nurse should attempt to extinguish the fire with the appropriate fire extinguisher. If unable to do so, the nurse should evacuate the area.

For each task identify the team member to which the nurse should delegate the task. Each task may be appropriate for more than 1 team member. Client 1: Perform prescribed procedure Client 2: Transport client for diagnostic testing Client 3: Administer prescribed medications Client 3: Administer prescribed medication Client 4: Provide prescribed wound care Client 4: Perform prescribed testing

Assistive Personnel: Clients Practical Nurse: Clients

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? A) the nurse identifies a broken piece of equipment (B) A staff member does not show up to work her assigned shift (C) A client discovers that his dentures are missing (D) The nurse has a disagreement with the nursing supervisor about inadequate staffing

C

(NGN) A nurse is caring for a client who is exhibiting increased agitation. The nurse offered toileting, lowered the lights in the clients room, and closed door to clients room. Nurses Notes: 2218: Provider contacted no new prescriptions received. 2220: Client remains agitated and repeats, "I am getting out of this bed and leaving this place." The nurse states. "You may not climb out of bed" and applied a wrist restraint and raised all bedside rails. Complete the following sentence by using the lists of options

The nurse is at risk for false imprisonment as evidenced by applying wrist restraints to the client. R: All nurses must understand the legal implications associated with nursing practice. Torts are civil wrongful acts which include intentional, unintentional, or quasi-intentional. Restraining or inhibiting a clients freedom including raising bed rails or apply wrist restraints without provider prescriptions is considered false imprisonment and an intentional tort which may result in civil or criminal actions.

NGN Which items should the nurse manager include in unit meeting? For each identified item, indicate if the nurse manager should include during unit meeting or if the content should be addressed with a specific individual team member.

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