Management B

A charge nurse in a skilled care facility identifies an increased rate of client falls. Which of the following statements to the nursing staff indicates the charge nurse is addressing the problem with an autocratic leadership style?

"I've made it mandatory for all nursing staff to attend an educational session on reducing client falls." -This statement indicates an autocratic style of leadership. An autocratic leader makes independent decisions about how to address a problem without seeking input from nursing staff.

A nurse is reinforcing teaching about home safety with an older adult client. Which of the following client statements indicates an understanding of the teaching?

"I should participate in a supervised exercise program." -The nurse should instruct the client to participate in a supervised exercise program regularly to maintain joint flexibility, muscle strength, and balance, and reduce the risk for falls.

A nurse is assisting with a presentation about preparing a home disaster supply kit at an community health fair. Which of the following statements by a participant should the nurse identify as understanding of the information?

"I will purchase canned fruit for the kit." -A home disaster kit should include nonperishable food items, which require no cooking or preparation and little water. Therefore, the nurse should identify the inclusion of canned fruit as an understanding of the information.

A nurse is reinforcing discharge teaching with a client who has a new prescription for home oxygen therapy. Which of the following client statements indicates understanding of the teaching?

"I will schedule monthly maintenance appointments for my equipment." -The client should schedule monthly appointments for maintenance of oxygen equipment to ensure it is working correctly.

A nurse is verifying informed consent with a client who is scheduled to have a total open abdominal hysterectomy with bilateral salpingo-ooophorectomy for the treatment of uterine cancer. The nurse should notify the provider for which of the client statements?

"I wish I knew if there was another way to treat this other than surgery." -The nurse should contact the provider to clarify the procedure and other options with the client. It is the provider's responsibility to inform the client of any other treatment options.

A newly licensed nurse is caring for a client who requires a straight catheterization. The nurse informs the charge nurse that he has only observed the procedure on two occasions. Which of the following responses should the charge nurse make?

"Let's discuss the procedure and I'll assist you with it the first time." -With this response, the charge nurse takes responsibility for coaching the newly licensed nurse by providing direct instruction and ensuring safe, effective care for the client.

A nurse in a provider's office is reinforcing discharge teaching with an adult client who has a new prescription for ear drops for an inner ear infection. Which of the following instructions should the nurse include?

"Lie on your side when preparing to instill the ear drops." -The nurse should instruct the client to lie on her side with the affected ear upward to instill the ear drops.

A nurse is discussing the meaning of the utilitarianism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this ethical theory?

"Utilitarianism provides the greatest good for the greatest number of people." -The nurse indicates an understanding of the ethical theory of utilitarianism by stating that the basis for this theory provides the greatest good for the greatest number of people.

A nurse in a long-term care facility is caring for an older adult client who has heart failure and is refusing to take a new medication. Which of the following responses should the nurse make?

"You have the right to refuse the medication." -The nurse should recognize the client's right to refuse the medication to support the client's autonomy. The nurse should document this in the client's medical record and notify the provider.

A charge nurse is planing a discussion concerning scope of practice with a newly licensed nurses. Which of the following tasks should the charge nurse identify as within the PN's scope of practice? (select all that apply)

*Plan nursing care for clients who have complicated diagnoses is (incorrect.) -It is within the PN's scope of practice to contribute to the plan of care for clients who have stable, rather than complicated conditions. *Delegate the care of a client to an RN is (incorrect.) -It is within the PN's scope of practice to assign the care of a client to an assistive personnel or another PN, not an RN. *Participate in health promotion counseling for a client is (correct.) -It is within the PN's scope of practice to participate in counseling for client health promotion. *Evaluate a client's response to nursing interventions is (correct.) -It is within the PN's scope of practice to participate in the evaluation of a client's responses to nursing interventions. *Assist in the development of unit policies affecting client care is (correct.) -It is within the PN's scope of practice to assist in the development of policies and procedures.

A nurse is assisting with the admission of a client who reports that she signed advance directives during a previous admission. Which of the following actions should the nurse take? (Select all that apply)

*Require the client to complete new advance directives for this admission is (incorrect.) -Having advance directives is the client's right, not a requirement. *Document in the client's medical record that she has advance directives is (correct.) -According to the Patient Self-Determination Act, the client's medical record should indicate whether or not she has advance directives. *Ensure that copies of the client's advance directives are located in her chart is (correct.) -Having copies of the client's advance directives in the medical record ensures that the health care team is aware of her wishes regarding health care decisions. *Inform the oncoming nurse of the client's advance directives during change-of-shift report is (correct.) -The nurse should discuss the client's advance directive status with nurses who will be directly providing client care. *Contact the facility chaplain to discuss the advance directives with the client is (incorrect.) -The nurse should not discuss the client's status with anyone who is not directly involved with the client's care without her consent.

A nurse is assisting in planning care for a client who has heart failure. Which of the following interventions should the nurse include? (select all that apply)

*Restrict sodium intake to 4 g per day is (incorrect.) -A client who has heart failure should receive less than 1.5 g of sodium per day. *Administer furosemide 40 mg PO daily is (correct.) -A client who has heart failure can benefit from a loop diuretic, such as furosemide, to reduce pulmonary and peripheral edema. *Place the client in supine position when in bed is (incorrect.) -A client who has heart failure should be placed in semi- to high-Fowler's position when in bed to decrease dyspnea. *Apply oxygen to keep SpO2 greater than 95% is (correct.) -A client who has heart failure might require supplemental oxygen to maintain an adequate SpO2 level. A SpO2 greater than 95% is an acceptable outcome. *Obtain daily weight is (correct.) -The nurse should obtain a daily weight for a client who has heart failure to provide data about fluid balance.

A nurse is assisting with triage following a mass casualty event. The nurse should recommend that which of the following clients be attended to first?

A client who has a crush injury to the pelvis and whose pedal pulse in the right foot is absent -A client who has a pelvic crush injury and an absent pulse to the lower extremity has an immediate threat to life and limb and requires emergent care for survival. When using the survival approach to client care, the nurse should give priority to this client.

A nurse is participating in a disaster drill and is assigned to assist with clients in the yellow tag staging area. The nurse should expect to assist in treating which of the following clients?

A client who has burns to the trunk and legs -The nurse should expect this client to have a yellow tag because this client's injuries require treatment that can be delayed.

A nurse is assisting with the selection of client to discharge to make beds available following a tornado in the community. Which of the following clients should the nurse recommend for discharge

A client who is recovering from a laparoscopic appendectomy that was performed 24 hr ago -A client who had an appendectomy without complications is often discharged the day of or the day after surgery. The nurse should recommend this client for discharge because this client has a low risk for an adverse event.

A nurse on a pediatric unit is assisting with the care of four clients. Which of the following clients should the nurse plan to see first?

A preschooler who has respiratory syncytial virus and is wheezing -When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority client is the preschooler who is wheezing because this client is at risk for a possible airway obstruction.

A nurse is assisting with the development of a presentation for newly licensed nurses regarding client confidentiality. Which of the following actions should the nurse include as an example of a breach of client confidentiality?

Accessing client medical records from other units to compare outcomes with currently assigned clients -The nurse should only access the medical records of currently assigned clients. Accessing client records from other units is a breach of client confidentiality and can result in disciplinary and legal action.

A nurse is planning to delegate care for a group of clients following change-of-shift report. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)?

Applying bilateral sequential compression devices to a client's legs -The nurse should delegate applying sequential compression devices to an AP because this skill is used routinely in client care, creates minimal safety risk for the client, and is within the range of function for an AP.

A nurse is completing documentation on the computer at the nurse's station when an assistive personnel (AP) requests to use the computer to enter morning vital signs. Which of the following actions should the nurse take?

Ask the AP to find another computer. -The nurse should ask the AP to find another computer that is not in use so that recording of information is completed in a timely manner.

A nurse at a rehabilitation facility is supervising a newly hired assistive personnel {AP} during the transfer of a client from the bed to a chair. Which of the following actions by the (AP) during the transfer of the client

Bends at the knees -Bending at the knees increases stability by using larger muscles and demonstrates safe transfer technique.

A nurse is serving on a performance improvement committee which is reviewing client falls. The data shows that most falls occur between 2000 and 200. Which of the following recommendations should the committee make?

Check on clients hourly -Evidence-based practice has shown that performing hourly rounds to provide assistance with toileting, pain, or client positioning is effective in reducing falls.

A nurse is assisting with the discharge of a client who was in a motor-vehicle crash 24 hr ago. The client tells the nurse "My vision seems blurry, and I am having difficulty speaking clearly." Which of the following actions should the nurse take first?

Check the client for indications of increased intracranial pressure. -The first action the nurse should take using the nursing process is to collect data from the client. By checking the client for indications of increased intracranial pressure, the nurse can determine if the client has any neurological deficits and identify findings to report to the charge nurse and the provider.

A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. The client has a new diagnosis of diabetes and his partner is at the bedside. Which of the following actions should the nurse take?

Contact an interpreting service via telephone to assist with the instructions. -The nurse should contact an interpreting service to assist in communicating discharge information to the client if a medical interpreter is not available in person. The use of a medical interpreter ensures that medical information is accurately communicated to the client.

A charge nurse is discussing legal issues with a newly licensed nurse. Which of the following actions should the charge nurse identify as negligence?

Failing to provide one-to-one observation for a client who is suicidal. -Failure to provide care according to established standards of care is negligence. Failing to provide one-to-one observation to a client who is suicidal puts the client at risk for self-injury.

A nurse is assisting an RN with a developing a meal plan for a client who has neutropenia. Which of the following foods should the nurse recommend to include?

Fried Fish -Fried fish is an appropriate food choice to include in the meal plan. Clients who have neutropenia should avoid undercooked meats to reduce the risk for acquiring foodborne illnesses.

A nurse in a long-term care facility is caring for a client who is refusing his prescribed medication. Which of the following actions should the nurse take first?

Identify the client's concerns about taking the medications. -The first action the nurse should take when using the nursing process is to collect data from the client. By identifying the client's concerns and reasons for refusing the medications, the nurse can determine which actions to take next to prevent worsening of the client's condition.

A nurse is observing an assistive personnel (AP) provide care for a group of clients. The nurse should intervene when the AP dons gloves prior to performing which of the following tasks?

Making a surgical bed for a client returning from surgery -Health care workers wear gloves to protect themselves from exposure to potentially infectious matter, such as blood or wound drainage. It is not necessary to use gloves when making an unoccupied surgical bed. Therefore, this is a waste of supplies and requires intervention by the nurse.

A nurse realizes she has administered the wrong medication to a client. Which of the following actions should the nurse take first?

Monitor the client's vital signs. -The greatest risk to this client is injury from receiving the wrong medication. Therefore, the priority action is to collect data from the client. By checking the client's vital signs, the nurse can determine if the client is experiencing an adverse reaction and whether immediate intervention is needed.

A nurse is providing care for a group of clients who have signed a general consent for treatment. The nurse should identify that which of the following procedures require an additional written informed consent?

Performing an amniocentesis -The nurse should ensure that the client has provided additional written informed consent prior to an invasive procedure, such as an amniocentesis.

A nurse in a long-term care facility is preparing to demonstrate administration of a cleansing enema to a group of newly licensed nurses. Which of the following actions should the nurse plan to take during the demonstration?

Place the client in a left side-lying position -The nurse should place the client on his left side, which allows the solution to flow by gravity into the sigmoid colon.

A nurse is participating in discharge planning for a client who has a new tracheostomy. Which of the following equipment should the nurse ensure is available for providing care for the client at home?

Portable suction -The nurse should ensure that a portable suction device and other suctioning equipment is available in the home to clear respiratory secretions.

A nurse is assisting with the development of an in-service about the process of evidence-based practice. Which of the following actions should the nurse include as the first step of this process?

Question a current clinical practice that does not seem effective. -According to the steps of evidence-based practice, the nurse should include to first question a current clinical practice that doesn't seem effective to identify a problem-focused trend to investigate further.

A charge nurse notices a nurse on the unit arriving to work 30 minutes late. The nurse appears unkempt and has slurred speech. Which of the following actions should the charge nurse take first?

Reassign the nurse's clients to another nurse. -The greatest risk is to allow an impaired nurse to care for clients. Therefore, the first action the charge nurse should take is to remove the nurse from the unit and reassign the nurse's clients to another nurse to prevent harm.

A nurse is reinforcing teaching with a newly licensed nurse about ethical principles to consider during client care. Which of the following actions should the nurse include as an example of client advocacy?

Relaying a client's concerns about an upcoming procedure to the provider -Acting as an intermediary between the client and other providers is an example of advocacy.

A nurse is supervising an assistive personnel (AP) fax a client's morning laboratory results to a provider's office. Which of the following actions by the AP requires intervention by the nurse?

Sends laboratory results from the past week -The AP should only send the information requested by the provider. The amount of information sent by fax should not exceed what was requested or required for immediate clinical needs.

A nurse is discussing time management with a newly licensed nurse. Which of the following actions should the nurse recommend to organize daily assigned client tasks?

Setting goals -The nurse should establish goals, according to assigned clients' needs and plans of care, at the beginning of each shift as an effective method of time management.

A nurse is assisting with the care of an older adult client who is recovering from a stroke and is experiencing difficulty swallowing and performing ADLs. The client will be living with his adult son following discharge. The nurse should recognize that which of the following client referrals has the highest priority?

Speech Therapy -When using the safety vs. risk reduction approach to client care, the greatest risk to this client is aspiration and airway compromise from difficulty swallowing. Therefore, the priority referral is for speech therapy. A speech therapist specializes in evaluation, management, and improvement of swallowing difficulties.

A nurse is collecting data from a client following abdominal surgery. The nurse should recognize which of the following client findings is the priority to report to the provider?

Surgical dressing saturated with bloody drainage -When using the airway, breathing, and circulation approach to client care, the nurse determines that the priority finding to report to the provider is the surgical dressing saturated with bloody drainage. This finding indicates the client is possibly experiencing postoperative hemorrhage, which can lead to hypovolemia and shock.

A nurse is collecting data from a client and notices smoke coming from and electrical outlet. Which of the following actions should the nurse take first?

Take the client out of the room -The greatest risk to this client is injury from smoke or fire. Therefore, the first action is to take the client out of the room and away from danger. This action follows the Rescue, Activate, Confine, Extinguish (RACE) protocol.

A nurse at a rehabilitation facility is participating in an interprofessional care conference for a client who is 1 week postoperative following an above-the-knee amputation. Which of the following findings is the priority for the nurse to report at the conference?

The client's incision site has purulent drainage. -The greatest risk to this client is postoperative infection, which is indicated by the presence of purulent drainage at the incision site and can cause osteomyelitis. Therefore, this is the priority finding for the nurse to report at the conference.

A nurse assisting with disaster triage is examining a client who has a large open wound to the lower extremity. Which of the following actions should the nurse take?

Tell the client she should receive treatment within 2 hr. -When performing disaster triage, the nurse should assign clients who have a large, open wound to the yellow, or urgent category. This is the second-priority client category, and clients who are in this category should receive treatment after the emergent group, but within 30 min to 2 hr.

A nurse is contributing to the plan of care for a group of clients. Which of the following scenarios demonstrates effective use of time management?

The nurse groups activities for a surgical client based on the client's pain medication schedule. -The nurse should anticipate when the client will need pain medication and schedule care activities at a time when the client is most comfortable and able to move, which will assist the client to meet goals and allow the nurse to plan care more effectively.

A nurse is caring for a client who is recovering following a total hip arthroplasty. The nurse receives a telephone call from the client's sister requesting information about the client's status. Which of the following actions should the nurse take?

Transfer the call to the patient -The nurse should allow the client to provide information to whomever they choose. This action protects the client's right to privacy under HIPAA.

A nurse assisting with the care of a client who suddenly becomes unconscious and requires emergency surgery. The client does not have advance directives and the only family member available is the client's 14-year-old daughter. Which of the following actions should the nurse plan to take?

Transport the client to the operating room with implied consent. -In an emergency, if it is not possible to obtain informed consent from the client, consent is implied because it is assumed that the client would want the medically necessary surgical treatment.

A nurse is assisting with the development of a slide presentation for staff education about preventing medication errors. Which of the following actions should the nurse take when developing the slides?

Use sentences that have a maximum of six words. -When developing effective slides for a slide presentation, the nurse should keep sentences short and limit the number of words to five or six per sentence.

A nurse is participating in a peer evaluation system based on overall performance of its nursing staff. Which of the following strategies ensures that the peer evaluation is impartial and fair?

Uses the same objective measurement tool for all nurses -An objective measurement tool based on established standards provides consistent criteria for evaluation and decreases the amount of subjectivity.

A nurse is observing a newly licensed nurse administer ophthalmic medication to a client. Which of the following actions should the newly licensed nurse take first?

Verify the medication with the client's medication administration record (MAR). -Evidence-based practice indicates the first action the nurse should take when administering ophthalmic medication is to validate the client's name, the name and dosage of the medication, and the medication prescription, route, and time with the client's MAR.

A newly hired nurse recognizes that the unit staff and nurse manager seem to be in constant conflict. The nurse should identify that the nurse manager is using which of the following conflict management approaches when she decides that her plans are best and the unit staff is no longer trying to resolve conflict>

Win-Yield -The nurse should identify the unit is using the win-yield approach to conflict management. With this approach, the manager is always right and the staff is no longer trying to resolve conflict, which creates an oppressed working environment on the unit.

A nurse is delegating a collection of a random stool specimen to an assistive personnel (AP), which of the following information should the nurse provide?

Wrap tongue blades used to retrieve the specimen in a paper towel prior to disposal. -The nurses should instruct the AP to use one to two tongue blades to move the stool specimen to the collection container. After transferring the stool, the AP should wrap the tongue blades in a paper towel before discarding them in the trash to prevent others from accidentally touching the contaminated surfaces.

A nurse is contributing to the plan of car for a client who states he is a devout Hindu. To adhere to the client's religious dietary practices, which of the following food options should the nurse offer to the client?

Yogurt -The nurse should offer yogurt as a food option for the client who is a devout Hindu because dairy products are believed to enhance spiritual purity.