Managed Care

Which task may a nurse delegate to a nursing assistant? a) Assisting a client who had surgery to ambulate in the hallway b) Administering an antacid to a client with symptoms of heartburn c) Taking orthostatic blood pressure readings on a client on a new medication d) Irrigating a nasogastric (NG) tube

a) Assisting a client who had surgery to ambulate in the hallway

The client with major depression states, "I'm too tired to get out of bed to go to group. I just want to rest." The nurse should tell the client: a) "I'll let you rest for as long as you need." b) "You've been in bed long enough and need to get up." c) "Attending group is an important part of your treatment plan." d) "Perhaps you'll feel better later on."

c) "Attending group is an important part of your treatment plan."

nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include? a) "Because of the increase in home burglaries involving the elderly, these clients should have burglar bars on every window in the home." b) "Most accidental injuries among the elderly are automobile-related. Elderly clients should have vision testing every 6 months while they're still driving." c) "Most falls among the elderly occur outside the home. Clients should confine themselves to their homes as much as practical." d) "Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."

"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."

A staff nurse on a pediatric unit has a four-client assignment. Which child should the nurse assess first? a) A 10-year-old child with asthma whose oxygen saturation levels are dropping b) An 8-year-old child admitted from the postanesthesia care unit who's complaining of pain c) A 7-year-old child whose mother is waiting for discharge instructions d) A 9-year-old child with a broken leg who wants help moving from the bed to the chair

A 10-year-old child with asthma whose oxygen saturation levels are dropping

The nurse is planning care for a neonate to prevent neonatal heat loss immediately after birth. To conserve heat and help the infant maintain a stable temperature, the nurse should: a) Nestle the neonate against the crib wall. b) Postion the neonate lying in an open crib with a diaper on. c) Place a hat on the neonate's head and wrap the neonate in a blanket. d) Bathe the neonate with warm water.

Place a hat on the neonate's head and wrap the neonate in a blanket.

A registered nurse (RN) is supervising the work of a licensed practical nurse (LPN) who's caring for a client diagnosed with a terminal illness. Which statement by the LPN should be corrected by the RN? a) "The law says you must write a new living will each time you're admitted to the hospital." b) "Some clients write living wills indicating their end-of-life preferences." c) "Some people tell their physicians they don't want to have cardiopulmonary resuscitation." d) "You could designate someone to make end-of-life decisions when you can't make them yourself."

a) "The law says you must write a new living will each time you're admitted to the hospital."

A nurse is administering medications to a client diagnosed with hepatitis B. When the nurse hands the client his/her medications, the client says, "I would rather not take that pill or any others. I know there is no cure for hepatitis B." The nurse recognizes that the client is expressing feelings of hopelessness about the diagnosis. Select the best responses by the nurse. Select all that apply. a) "You seem frustrated. Would you like to talk?" b) "You have the right to refuse any medications. Would you like to discuss your feelings about this disease?" c) "Legally, I am obligated to give you this medication." d) "You can lead a long and fairly healthy life if you are compliant with your medications." e) "I'm going to let the physician talk to you."

a) "You seem frustrated. Would you like to talk?" b) "You have the right to refuse any medications. Would you like to discuss your feelings about this disease?" d) "You can lead a long and fairly healthy life if you are compliant with your medications."

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. a) Monitor neurologic status using the Glasgow Coma Scale. b) Stimulate the client with active range-of-motion exercises. c) Elevate the head of the bed 15 to 30 degrees. d) Encourage the client to cough and take deep breaths. e) Contact the health care provider if ICP is greater than 20 mm Hg.

a) Monitor neurologic status using the Glasgow Coma Scale. c) Elevate the head of the bed 15 to 30 degrees. e) Contact the health care provider if ICP is greater than 20 mm Hg.

Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. a) Performing a blood glucose check b) Assessing a client's pain c) Evaluating a client's response to a blood pressure medication d) Taking a client's vital signs e) Documenting a client's oral intake

a) Performing a blood glucose check d) Taking a client's vital signs e) Documenting a client's oral intake

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. a) Providing skin care following bowel movements. b) Maintaining intake and output records. c) Obtaining the client's weight. d) Evaluating the client's response to antidiarrheal medications. e) Assessing the client's bowel sounds.

a) Providing skin care following bowel movements. b) Maintaining intake and output records. c) Obtaining the client's weight.

The nurse is performing the initial assessment on a middle age woman recently diagnosed with Cushing's syndrome. The nurse reviews the history and physical (See chart). The nurse should develop a plan with the client to manage which of the following? Select all that apply. a) Slow healing. b) Changes in physical appearance. c) Risk for infection. d) Low blood volume. e) Risk for injury.

a) Slow healing. b) Changes in physical appearance. c) Risk for infection. e) Risk for injury.

A nurse on a neurologic unit has completed assessments on five clients. Which task should the nurse delegate to the nursing assistant? a) Taking vital signs b) Inserting an nasogastric (NG) tube c) Administering a client's antiseizure medications d) Completing the admission assessment

a) Taking vital signs

A client is refusing to take the prescribed oral medication. Which of the following measures by the nurse can be used to get the client to take the medication? Select all that apply. a) Having a family member give the medication b) Asking the client the reason for not taking the medication c) Crushing the medication and hiding it in apple sauce d) Explaining the purpose of the medication to the client e) Suggesting a liquid form of the medication instead of a pill

b) Asking the client the reason for not taking the medication d) Explaining the purpose of the medication to the client e) Suggesting a liquid form of the medication instead of a pill

A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb all the way up to the hips. The nurse should do which of the following next? Select all that apply. a) Call the family to come in to visit. b) Check for advancing levels of paresthesia. c) Have the client perform ankle pumps. d) Notify the health care provider of the change. e) Place respiratory resuscitation equipment in the client's room.

b) Check for advancing levels of paresthesia. d) Notify the health care provider of the change. e) Place respiratory resuscitation equipment in the client's room.

Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply. a) Teach clients the proper use of the incentive spirometer. b) Reposition clients for pain relief. c) Tell the nurse if clients report they are having pain. d) Assess I.V. insertion site for redness. e) Empty and measure indwelling urinary catheter collection bags.

b) Reposition clients for pain relief. c) Tell the nurse if clients report they are having pain. e) Empty and measure indwelling urinary catheter collection bags.

The nurse observes a surgeon explaining the procedure for an appendectomy to a client and asking the client to sign the consent for surgery. The nurse is aware that the client is Chinese and does not speak the native language fluently. Which of the following is the best action for the nurse to take to advocate for the client? a) Allow the client to sign the consent because delaying surgery might cause harm to the client. b) Suggest that a hospital interpreter explain the procedure to the client before the consent is signed. c) Draw a picture for the client to indicate the location of surgery and where the incision will be made. d) Ask the client's spouse to explain the procedure to the client in Chinese and to report the client's understanding of it.

b) Suggest that a hospital interpreter explain the procedure to the client before the consent is signed.

As the nurse is turning off the television, a client with bipolar disorder, manic phase, says, "I want the television on so I can watch the late show. I'm not tired and you can't tell me what to do. I want it on!" The nurse should tell the client: a) "I'll let you watch television just this once. Don't tell anyone about this." b) "I'll turn the television off when you get sleepy. Don't ask me to do this again." c) "The television goes off at 10 p.m. I've been telling you this for the past three evenings." d) "Television hours are from 7 to 10 p.m. It's 10 p.m., and the television goes off so everyone can sleep."

d) "Television hours are from 7 to 10 p.m. It's 10 p.m., and the television goes off so everyone can sleep."

A registered nurse and a nursing assistant are caring for a group of clients. Which client's care may safely be delegated to the nursing assistant? a) A client who requires neurological assessment every 4 hours after sustaining a spinal cord injury in a motor vehicle accident that left him with paraplegia b) A client with uncontrolled diabetes mellitus who underwent radical suprapubic prostatectomy 1 day ago and has an indwelling urinary catheter draining yellow urine with clots c) A client who underwent surgery 12 hours ago whose suprapubic catheter is draining burgundy-colored urine d) A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids.

d) A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids.

The unit secretary who transcribes the physicians' prescriptions asks the nurse to interpret an illegible order. The nurse should: a) Interpret the order according to the client's previous medication record. b) Clarify the order with the pharmacist. c) Clarify the client's medications with the client's family. d) Clarify the order by calling the physician.

d) Clarify the order by calling the physician.

A client diagnosed with pneumonia refuses the prescribed oral antibiotic. The client is alert and oriented, vital signs are within normal range, and crackles are scattered throughout the posterior left lower lobe of the client's lung. Which actions should the nurse perform? Select all that apply. You selected: • Address the client's concern about the medication by clarifying its purpose. • Notify the physician. • Document that the client refused to take the medication.

• Address the client's concern about the medication by clarifying its purpose. • Notify the physician. • Document that the client refused to take the medication.