Module 5 HESI Management of Care

** A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first? Realigning the client Medicating the client with the prescribed analgesic Removing some of the traction weights Asking the client to wiggle her toes

Realigning the client

A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? A client who needs frequent ambulation with a walker A client who has undergone an arteriogram and requires close monitoring A client who requires periodic suctioning A client who needs a colostomy irrigation

A client who needs frequent ambulation with a walker

** A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? Nonmaleficence Autonomy Justice Fidelity

Nonmaleficence

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up? Select all that apply. A client who has just undergone surgery is getting relief from the prescribed pain medication. A client who has just undergone surgery has a urine output of more than 30 mL/hr. A client with a new diagnosis of diabetes mellitus is self-administering insulin. A client is performing his/her own colostomy irrigations. A client with a central venous catheter has a temperature of 100.6° F (38.1°C).

A client with a central venous catheter has a temperature of 100.6° F. (there really is only 1 answer so idk why it's a select all that apply)

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? Pulse Urine output Temperature Respiratory status

Respiratory status

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? Home care Physical therapy Occupational therapy Social services

Occupational therapy

A physician repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the physician tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? Reporting the primary health care provider to the chief of medicine at the hospital Discussing the situation with the nurse manager Stating to the physician, "I don't really care whether you report me. I am not writing your prescriptions." Fulfilling the physician's request

Discussing the situation with the nurse manager

A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict? Confronting the nurse regarding his/her behavior regarding the overtime policy Ignoring the complaints Avoiding assigning the nurse mandatory overtime Providing a positive reward system for the nurse so that the nurse will agree to work the mandatory overtime

Confronting the nurse regarding her behavior regarding the overtime policy

A case manager is reviewing progress notes in a client's medical record. Which notation indicates the need for follow-up? Client 1: Status post-mastectomy: 18 hours; Five milliliters of bloody drainage was emptied from the Jackson-Pratt drain. Client 2: Heart Failure; Crackles were heard in the lower lung lobes bilaterally on auscultation. Client 3: Status post-appendectomy: 24 hours; The surgical dressing is clean and dry. Client 4: Diabetes mellitus; Blood glucose level is 124 mg/dL (6.9 mmol/L).

Client 2 Heart Failure Crackles were heard in the lower lung lobes bilaterally on auscultation.

A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply. Family history Client response to treatments implemented that day Results of laboratory studies conducted that day Current diagnosis and any secondary diagnoses Steps used to perform the procedure for changing the client's sterile dressing at the gastrostomy tube site Client needs and priorities of care

Client needs and priorities of care Current diagnosis and any secondary diagnoses Results of laboratory studies conducted that day Client response to treatments implemented that day

A nurse manager discusses staff empowerment with the nursing team. The nurse manager explains that staff empowerment: Fosters the growth of others so that they are less dependent on the leader Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes Allows the staff to make every decision regarding employee scheduling

Fosters the growth of others so that they are less dependent on the leader

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first: Check the placement of the tube Check the client's apical pulse Check when the last medications were given Check when the last feeding was given

Check the placement of the tube

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is: Looking at what other communities are doing about school violence Conducting a community survey to assess community perceptions regarding school violence Distributing fliers that identify the causes of school violence to families in the community Teaching schoolchildren about the dangers of school violence

Conducting a community survey to assess community perceptions regarding school violence

A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict? Tell the LPN that his/her noncompliance will be documented in his personnel record Confront the LPN and encouraging him/her to express his/her feelings regarding the change Ignore the resistance Tell the LPN that a registered nurse will perform all of the computer documentation if he/she will document all intake and output and vital signs

Confronting the LPN and encouraging him to express his feelings regarding the change

The nurse reviewing a client's record sees that the following medications are prescribed. Which medication should the nurse plan to administer first? 1. Atorvastatin 10 mg orally 2. Zolpidem 5 mg orally daily 3. Ferrous sulfate 1 tablet orally 4. Levothyroxine 137 mg orally

Levothyroxine (Synthroid) 137mg orally

A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team does the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?

Social worker

A nurse planning care for her assigned clients. What does the nurse know about the purpose of the hospital's standards of care? Select all that apply. Provide competent care on the basis of current practice Provide direction for care on the basis of the client's diagnosis Identify methods of treatment Identify new care methods on the basis of current medical research Provide direction for the practice of nursing Evaluate current methods of treatment

Provide competent care on the basis of current practice Provide direction for the practice of nursing

A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he has gonorrhea." How should the nurse respond to the secretary? "Oh, really? I didn't see that!" "Yes, he does, but be sure not to discuss this with anyone else." "Yes, that's why we've imposed contact precautions." "We can't discuss a client's medical condition."

"We can't discuss a client's medical condition."

** A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? A client on bedrest who needs assistance with feeding A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures A client who must be turned and repositioned every 2 hours A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments

A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments

The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant? A client who is getting up to ambulate for the first time after surgery A client who has just undergone cardiac catheterization An unconscious client who requires oral care A client scheduled for a liver biopsy

An unconscious client who requires oral care

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? Call the client's primary health care provider Document the error in the client's chart Report the nurse who changed the IV solution Ask the nurse whether he/she intends to report the error

Ask the nurse whether she intends to report the error

** A nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? Asking the client to remove the medal until the x-ray has been completed Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms Telling the client that the medal and chain will be kept at the nurses' station for safekeeping while the client is undergoing the x-ray

Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms

A new nurse employed at a community hospital is reading the organization's mission statement. What statements suggest that the new nurse understands what the organization's mission is? Select all that apply. Includes the organization's purpose,goals or objectives Outlines what the organization plans to accomplish Incorporates statements of philosophy (beliefs) Describes the benefits available to employees Identifies the policies and procedures of the organization Defines the rules of the organization that the employees must follow

Includes the organization's purpose,goals or objectives Outlines what the organization plans to accomplish Incorporates statements of philosophy (beliefs)

A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. The most appropriate action for the nurse is to: Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery Contact the client's primary health care provider Report the incident to the nursing supervisor Tell the client that the nurse did the right thing in giving the enema

Report the incident to the nursing supervisor

** A client asks a nurse about the procedure for becoming an organ donor. The nurse tells the client: To speak with the chaplain about the psychosocial aspects of becoming a donor To let the primary health care provider know about the request so that it may be documented in the client's record That this decision must be made by the next of kin at the time of the client's death That anatomical gifts should be made in writing and signed by the client

That anatomical gifts must be made in writing and signed by the client

A nurse is assigned to care for four clients. Which client should the nurse assess first? A client scheduled for a colonoscopy A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask A client preparing for discharge after surgery A client requiring a tube feeding through a gastrostomy tube

A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. The nurse should first: Ask the nursing assistant to assist in getting the client back to bed Ask the nursing assistant to complete an incident report Contact the unit secretary on the intercom and ask that the client's primary health care provider be called Check the client's level of consciousness and vital signs

Check the client's level of consciousness and vital signs

Which of the following actions exemplifies the use of evidence-based practice in the delivery of client care? Donning sterile gloves to change an abdominal wound dressing Advising a client to agree to the treatment recommended by her primary health care provider Taking a rectal temperature from a client for whom bleeding precautions have been instituted Encouraging a client to take an herbal substance to treat his insomnia

Donning sterile gloves to change an abdominal wound dressing

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply. A client who requires transport to the radiology department in a wheelchair A client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter A client with a permanent tracheostomy A client requiring a gastrostomy tube dressing change A client with a Foley catheter for whom a 24-hour urine collection is in progress

A client who requires transport to the radiology department in a wheelchair A client with a Foley catheter for whom a 24-hour urine collection is in progress

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by: Calling the surgeon and asking that the risks be explained to the client Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room Reassuring the client that the risks are minimal Noting in the client's record that the client was not told about the risks of the surgery

Calling the surgeon and asking that the risks be explained to the client

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse tells the client that: A consent form is not needed if the problem is a sexually transmitted infection Anyone over the age of 18 years may sign a consent form for her treatment She will need to sign an informed consent form Her mother or father will need to be contacted for permission to treat her

She will need to sign an informed consent form

**An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client's parents but is unsuccessful. In regard to informed consent for the surgery: The nurse will prepare the client to undergo mechanical ventilation until the client's parents can be contacted The nurse will contact the hospital clergy to provide informed consent The nurse understands that consent is not needed The nurse will sign informed consent on behalf of the client and ask another nurse to witness the signature

The nurse understands that consent is not needed

** A nurse working the 7 am-to-3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first? A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am A client scheduled for a nuclear scanning procedure at 10 am A client scheduled for hemodialysis at 10 am A client scheduled for contrast computed tomography (CT) at noon

A client scheduled for hemodialysis at 10 am

** A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up? A client with a spinal cord injury transfers himself from a bed to a wheelchair. A client who exhibits signs/symptoms of increased intracranial pressure after a craniotomy. A client who has sustained a stroke dresses herself. Normal neurological findings are noted in a client with a cerebral aneurysm.

A client exhibits signs of increased intracranial pressure after a craniotomy.

A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse manager to deal with this situation? Documenting the problem in the nurse's personnel file Ignoring the situation Asking other staff members to cover for the nurse Confronting the nurse to discuss the behavior and initiate problem-solving measures

Confronting the nurse to discuss the behavior and initiate problem-solving measures

A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation? Provide an in-service educational session on aseptic technique for everyone on the nursing unit Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had his/her technique validated Inform the nurse who reported the occurrence that intravenous ports do not need to be cleaned with alcohol before medication administration Tell the nurse that it is inappropriate to report other nurses

Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated

** A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, "I don't want a bath. I've been up all night, and I'm clean enough." The student reports the client's refusal to the nurse in charge. Which action by the nurse in charge is appropriate? Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it Telling the nursing student to allow the client to rest Telling the client that the primary health care provider will be informed of the refusal of care Telling the nursing student to give the client the bath anyway

Telling the nursing student to allow the client to rest

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager? "You know how I hate to work overtime." "I have plans after work and will not be able to work overtime." "I will if you need me, but I am not happy about this." "I'm not working overtime today."

"I have plans after work and will not be able to work overtime."

** A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should: Administer cardiopulmonary resuscitation (CPR) Call the client's primary health care provider Contact the nursing supervisor for directions Contact the client's next-of-kin

Administer cardiopulmonary resuscitation (CPR)

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client's deltoid muscle. The RN determines that the LPN is performing the procedure correctly if the LPN: Places the client in the Sims position Administers the injection in the thigh Positions the client in a prone toe-in position Administers the injection 2 inches (5 cm) below the acromion process

Administers the injection 2 inches below the acromion process

** A physician writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the physician, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take? Contact the nursing supervisor Ask the nurse assigned to care for the client to administer the medication Verify the prescribed dose with the client before administering the medication Continue to transcribe the prescription

Contacting the nursing supervisor

** A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the physician. The physician verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. The nurse should first: Explain the procedure to the client, then remove the chest tube Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube Call the nursing supervisor Inform the primary health care provider that removal of a chest tube is not a nursing procedure

Inform the physician that removal of a chest tube is not a nursing procedure

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart so that he will: Be aware of the geographical area that the organization serves Understand the way an organization depicts how activities are arranged Be familiar with the organization's line of authority Be knowledgeable of how communication channels are established Be familiar with the beliefs and values of the organization Understand the organization's reason for existence

Understand the way an organization depicts how activities are arranged Be familiar with the organization's line of authority Be knowledgeable of how communication channels are established

A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member? A client with diarrhea for whom enteric precautions are in effect A client for whom contact precautions have been implemented and who requires frequent wound irrigations A client with metastatic cancer who is receiving a continuous infusion of intravenous morphine sulfate A client with a solid sealed cervical radiation implant

A client with a solid sealed cervical radiation implant

A nurse is planning the client assignments for the shift. Which client should the nurse assign to the nursing assistant? A client with diarrhea on whom contact precautions have been imposed A client with angina who needs to be ambulated for the first time since admission A client with a draining abdominal wound that requires frequent dressing changes A client who needs a blood transfusion

A client with diarrhea on whom contact precautions have been imposed

A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is "uncooperative and a real pain to care for." The nurse leader would most appropriately manage this issue by: Report the nurses' comments to administration Leave articles about judgmental opinions in the nurses' report room Discourage the judgmental comments Ignore the comments made about the client

Discouraging the judgmental comments

The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are part of the nurse's new role? Select all that apply. Assessing the client's needs for home supplies and equipment Prescribing treatments specific to the client's needs Evaluating and updating the plan of care as needed Coordinating consultations and referrals to facilitate discharge Establishing a safe and cost-effective plan of care with the client

Evaluating and updating the plan of care as needed Assessing the client's needs for home supplies and equipment Coordinating consultations and referrals to facilitate discharge Establishing a safe and cost-effective plan of care with the client

**A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply. A client who must be accompanied to physical therapy twice during the shift A client with a colostomy who requires reinforcement regarding the procedure for irrigation A client requiring a bed bath and frequent ambulation with a cane A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours A client who is confused and requires assistance with a shower

A client with a colostomy who requires reinforcement regarding the procedure for irrigation A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

A charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriate action for the charge nurse to take? Tell the staff member that she is not allowed to administer medications Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off Contact the nursing supervisor Ask the staff member how much alcohol she has consumed

Contact the nursing supervisor

A nurse enters a client's room to administer a medication that has been prescribed by the physician. The client asks the nurse about the medication. Which response by the nurse is appropriate? "You need to discuss this medication with your physician." "It's to help get rid of the swelling in your feet." "I know that it's for fluid buildup, and I think you've taken it before." "It's called furosemide, and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in y

"It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant? Ambulating a client with Parkinson's disease Providing hygiene to a client with dementia Assisting a client with an above-the-knee amputation in showering Assisting a client with dysphagia in eating

Assisting a client with dysphagia in eating

** A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act to: Identify healthcare policies in her state Be aware of hospital and long-term care facilities policies Be aware of the role of the professional nurse Know how to perform certain procedures

Be aware of the role of the professional nurse

A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client's injury, the nurse should: Call the nurse in charge of the day shift Ask the police officers who brought the client to the ED Check the unit policy for the protocol for the care of clients who have been sexually assaulted Ask a licensed practical nurse

Check the unit policy for the protocol for the care of clients who have been sexually assaulted

*A physician asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of his: Information power Referent power Position power Reward power Expert power Coercive power

Expert power

Which action by the nurse represents the ethical principle of beneficence? The nurse upholds a client's decision to refuse chemotherapy for lung cancer. The nurse follows a plan of care designed to relieve pain in a client with cancer. The nurse administers an immunization to a child even though it may cause discomfort. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.

The nurse administers an immunization to a child even though it may cause discomfort.

*A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, "The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection." Which of the following statements accurately describes the nurse's response to the client? The nurse could be charged with assault. The nurse could be charged with battery. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the physician. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease.

The nurse could be charged with assault.

A nurse calls a physician to question a prescription written for a higher-than-normal dosage of morphine sulfate. The physician changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes? The primary health care provider made an error in the written prescription for morphine sulfate. The primary health care provider was called to correct an error in the dosage of morphine sulfate. The primary health care provider was called to clarify the prescription for morphine sulfate. An incorrect dosage of morphine sulfate was prescribed and the primary health care provider was notified.

The primary health care provider was called to clarify the prescription for morphine sulfate.

A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act? Contacting a primary health care provider about a change in a client's blood pressure Checking neurological signs/symptoms in a client with a head injury Giving a verbal report to the nurse on the oncoming shift Using clean gloves to change a gastrostomy tube dressing

Using clean gloves to change a gastrostomy tube dressing

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately: Return to the medical care unit and discuss the assignment with the nurse manager on that unit Refuse to do the assignment Tell the nurse manager to call the nursing supervisor Ask the nurse manager of the intensive care unit (ICU) to discuss the assignment

Ask the nurse manager of the intensive care unit to discuss the assignment

A nurse is assisting a primary health care provider in assessing a hospitalized client. During the assessment, the primary health care provider is paged to report to the recovery room. The primary health care provider leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? Calling the nursing supervisor to obtain permission to accept the verbal prescription Changing the solution and rate of the IV fluid per the physician's verbal prescription Telling the primary health care provider that the prescription will not be implemented until it is documented in the client's record Asking the primary health care provider to write the prescription in the client's record before leaving the nursing unit

Asking the primary health care provider to write the prescription in the client's record before leaving the nursing unit

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after delegation of the tasks is: Allowing each staff member to make judgments when performing the tasks Assigning any tasks that were not completed to the next nursing shift Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Documenting completion of each task

Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task.

A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. What observed activity by the nursing assistant would lead the RN to conclude that the nursing assistant is performing the procedure incorrectly? Stands behind the client Grasps the security belt in the midspine area of the small of the client's back Positions the free hand on the client's shoulder Stands on the right side of the client

Stands behind the client

A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment? The RN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications. The LPN is assigned to care for a client with newly diagnosed diabetes mellitus who will need to be taught how to self-administer insulin. The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home. The LPN is assigned to provide discharge teaching about dressing changes and medications to a 35-year-old man.

The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home.

A nurse calls a physician to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The physician, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? The nurse calls a primary health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The primary health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide but does not specify the route of administration. What is the appropriate action on the part of the nurse? Call the nursing supervisor for assistance in determining the route of administration Administer the medication orally and clarifying the prescription once the primary health care provider has finished caring for the client in the emergency department Call the primary health care provider who gave the telephone prescription to clarify the prescription Administer the medication intravenously, because this route is generally used for clients with CHF

Calling the primary health care provider who gave the telephone prescription to clarify the prescription

A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following? During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The primary health care provider was notified. The client had an allergy to cefazolin sodium. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back. The primary health care provider was notified because a rash developed while the client was receiving cefazolin sodium.

During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The physician was notified.

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply. "It carries legal implications for task performance." "Accountability can be delegated." "You are not responsible for the care that you ask others to complete." "It refers to the process of answering or being responsible for what occurs." "You are responsible for your own actions."

"You are responsible for your own actions." "It carries legal implications for task performance." "It refers to the process of answering or being responsible for what occurs."

** An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first? Peripheral pulses Blood pressure (BP) Heart rate Radial pulse rate

Peripheral pulses

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding? "The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis." "The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge." "The care map is a plan that is used only by the nurse to provide client care." "The care map is developed by a nurse and identifies nursing diagnoses."

"The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge."

**A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will she plan to care for first? A client scheduled for physical therapy at 11 am A client in skeletal traction who has just received pain medication A client who is scheduled for surgery at 1 pm A client who is able to perform activities of daily living independently

A client who is scheduled for surgery at 1 pm

A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace? Ask the client whether the necklace is gold Ask the client to remove the necklace and place it in the top drawer of the bedside table Ask the client for permission to lock the necklace in the hospital safe Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure

Ask the client for permission to lock the necklace in the hospital safe

**The nurse notes that a physician has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take? Contact the primary health care provider Administer the medication Plan to have the nurse on the next shift administer the medication Draw up the medication in a syringe

Contacting the physician (no route specified)

A nurse manager arrives at work and is immediately faced with several activities that require his attention. Which activity will the nurse manager attend to first? A phone message from employee health services A phone message from a client's wife Stocking the medication closet Client assignments for the day

Client assignments for the day

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if he: Allows time for unexpected tasks Gathers supplies before beginning a task Documents task completion and client information at the end of the day Prioritizes client needs and daily tasks

Documents task completion and client information at the end of the day

A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (unlicensed assistive personnel)? A client who had a mastectomy 2 days ago A client with renal calculi whose urine must be strained A client scheduled for a laparoscopic cholecystectomy A client scheduled for a cardiac stress test

A client with renal calculi whose urine must be strained

A nurse, newly employed by a home health agency, is told that the organization's decision-making process is centralized. What does the nurse determine that the authority to make decisions is vested in? Select all that apply. All nursing employees, pharmacists, and hospital physicians A narrower span of control Many individuals, with decisions filtering down to the individual employee A few individuals, such as the board of directors Decision-making authority concentrated in the top level of the hierarchy Every employee

A narrower span of control A few individuals, such as the board of directors Decision-making authority concentrated in the top level of the hierarchy

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse? Telling the client that she needed to ask these questions before signing the informed consent for surgery Informing the client that she has the right to cancel the surgical procedure if she wishes Contacting the surgeon and requesting that he/she visit the client to answer her questions Telling the client that it is her surgeon's responsibility to explain the procedure

Contacting the surgeon and requesting that she visit the client to answer her questions

** A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply. Have some similarity to policies and procedures Are statements that relate only to the agency in which the nurse is employed Are specific guidelines Describe an acceptable level of client care Define professional practice Are authoritative statements that describe a common level of performance

Define professional practice Have some similarity to policies and procedures Are authoritative statements that describe a common or acceptable level of client care or performance

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should: Ask the television crew to interview the individuals attending the program individually Explain to the television crew that videotaping is not allowed Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization Allow the television crew to videotape the program

Explain to the television crew that videotaping is not allowed

A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral? Occupational therapy Home care Social services Physical therapy

Home care

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client? Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times Placing the client in a semiprivate room with a cohort client Using a surgical mask when entering the client's room Keeping the door to the client's room closed

Keeping the door to the client's room closed

A nurse employed in a community hospital as a nurse manager. What does the nurse understand that in this position, the term authority most appropriately refers to? Select all that apply. Power of an individual to approve an action Carrying the legal responsibility for others' performance of tasks Accepting the responsibility for the actions of others Being responsible for what staff members do Ability to command an action The official power to see that an organizational decision is enforced

Power of an individual to approve an action Ability to command an action The official power to see that an organizational decision is enforced

A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem? Documenting the employee's behavior in the personnel file Telling the employee that he/she will be fired if he/she calls in sick again Reminding the employee of the employment standards of the agency Reporting the employee to administration

Reminding the employee of the employment standards of the agency

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? She will have to discuss the prescribed test with the client. A bone scan is being performed. The radiology department is not clear as to which test has been prescribed. She can read the client's medical record to determine what the primary health care provider prescribed.

She will have to discuss the prescribed test with the client.

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first? Submerge the end of the chest tube in a bottle of sterile water Clamp the chest tube with a Kelly clamp Instruct the client to inhale and hold his breath Call the primary health care provider

Submerge the end of the chest tube in a bottle of sterile water

The nursing instructor asks a student to name an example of false imprisonment. Which of the following situations reflects a violation of this client right? Observing the provision of care to the client without the client's permission Telling the client that he or she may not leave the hospital Performing a procedure without consent Threatening to give a client a medication against his or her will

Telling the client that he or she may not leave the hospital

A physician informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The physician tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond? Telling the primary health care provider that the client would probably want to die in peace Telling the primary health care provider that "slow codes" are not acceptable Telling the primary health care provider that if the client stops breathing, the primary health care provider will be called before any other actions are taken Telling the primary health care provider that all of the nurses on the unit agree with this plan

Telling the physician that "slow codes" are not acceptable

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation? The client's wound is healing well The client is voiding large amounts The client seems anxious The client's intake was 360 mL

The client's intake was 360 mL

A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should: Tape the wedding band in place Explain to the client why the wedding band must be removed Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery Ask the client whether she would like to remove the wedding band or wear it to surgery

Explain to the client why the wedding band must be removed

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type of audit? Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed

Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

In which situation is the nurse upholding the ethical principle of fidelity? Select all that apply. Contacting the primary health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan Providing complete information regarding treatment options to each client with a cancer diagnosis. Allowing a client to decide when to receive daily hygiene care Providing complete information regarding treatment options to a client with newly diagnosed cancer Keeping promises made to clients. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion

Contacting the physician about the client's request to incorporate complementary therapies for pain into the treatment plan Keeping promises made to clients.

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first? Check to see whether it is time for more pain medication Reassess the client in 30 minutes Contact the primary health care provider Encourage the client to continue active range of motion exercises of the left arm

Contacting the primary health care provider

** A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next? Rechecking the pulse oximetry reading Oxygenating the client with 100% oxygen Calling the respiratory therapist Calling the primary health care provider

Oxygenating the client with 100% oxygen

** Which of the following situations is an example of the use of evidence-based practice in the delivery of client care? Encouraging a client who has had a stroke to consume thin liquids and foods Immediately picking up a dislodged radiation implant with gloved hands and placing it in a lead container Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

A man who is visiting his wife in a long-term care facility for people with Alzheimer's disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital primary health care provider that the client has no other family members and that his wife is mentally incompetent. The client's primary health care provider writes a DNR order. What knowledge by the registered nurse indicates a need for further education? That the DNR order has been ethically and legally implemented. That everything possible must be done if the client stops breathing. That the client's other medical conditions must be treated. That the DNR order will be reviewed according to hospital policy.

That everything possible must be done if the client stops breathing.

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. What does the nurse know that a DNR order means? Select all that apply. That it must be legally and ethically implemented. The DNR order may be changed once it is in effect The client is the responsible person who may change the DNR order. The DNR order requires frequent review as specified by state or agency policy That CPR can be started but no medications can be administered. The DNR order, as written on admission, must remain in effect for the duration of the client's hospitalization

That it must be legally and ethically implemented. The DNR order may be changed once it is in effect The client is the responsible person who may change the DNR order. The DNR order requires frequent review as specified by state or agency policy

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that: Oral consent is sufficient and that his request will be honored by all primary healthcare providers The DNR request should be discussed with the physician, who will write the order Consent must be obtained from the family The primary health care provider makes the final decision about a DNR request

The DNR request should be discussed with the physician, who will write the order

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply. Ask the nursing assistant to contact the primary health care provider during the nurse's break if a client's pain medication is not effective Ask the nursing assistant to monitor a client's tube feeding and to contact the nurse when the feeding bag is empty Ask the nursing assistant to administer a medication placed at the client's bedside if the client awakens Take the break in the staff lounge located on the nursing unit Inform the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby Conduct client rounds before taking the break

Conducting client rounds before taking the break Taking the break in the staff lounge located on the nursing unit