nclex-rn qbank princeton review

The nurse is caring for a client who underwent a colon resection one day ago. There is an order to assist the client with ambulation three times per shift while the client is awake. Which instruction by the nurse is most appropriate when assigning this task to the unlicensed assistive person (UAP)? "When assisting the client, be sure to ask about the intensity of the pain." "Have the client stand for at least two minutes before starting to walk." "Apply a gait belt around the client's waist if the client reports feeling dizzy." "Allow the client to sit on the side of the bed before assisting the client to stand and walk.

"Allow the client to sit on the side of the bed before assisting the client to stand and walk. Rationale: The only appropriate statement is to allow the client to sit on the side of the bed first, before standing and walking. It is not necessary to stand up for two minutes before starting to walk. A gait belt should not be used since the client had abdominal surgery; besides, the UAP should not assist clients to stand and walk if they report feeling dizzy. The UAP cannot assess clients (ask about the intensity of the pain).

The nurse manager is providing education to staff nurses on the importance of documents to communicate client information. Which of the following statements would require further teaching by the staff nurse? "The healthcare team reviews progress notes to make clinical decisions." "Utilization of a graphic record shows trends in client status." "An admission assessment is a good source for a record of routine care." "Discharge documents include a summary of care pri."

"An admission assessment is a good source for a record of routine care." Rationale: A flow sheet, not an admission assessment, is a documentation tool used to efficiently record routine aspects of nursing care (e. g. , wound care, hygiene, nutrition). An admission assessment provides results of client history and physical assessment which becomes a baseline for later comparisons as the client's condition changes. The graphic record is a form used to record specific patient variables where trends in client status may be monitored, such as pulse, respiratory rate, or fluid intake and output. The multidisciplinary healthcare team reviews progress notes to make clinical decisions. Discharge or transfer documents summarizes the care the client has received and the patient's condition on discharge.

The nurse is teaching the parent of a child who just had a tracheostomy inserted for subglottic stenosis. Which of the following statements would the nurse include regarding supplies needed for this procedure at home? "You will need sterile gloves for this procedure." "Old tracheostomy ties can be used as long as the site is cleansed." "An extra tracheostomy should be available in case of dislodgement." "Oxygen therapy is necessary during cleansing of the site."

"An extra tracheostomy should be available in case of dislodgement." Rationale: The nurse should teach the parent to gather the following supplies needed for tracheostomy care in the home: prescribed cleaning solution, precut gauze, clean tracheostomy ties, gloves (not sterile), and cotton-tipped applicators. An extra tracheostomy is essential in case of accidental dislodgement. Parents should be taught not to use the old tracheostomy ties, but to use new ones after the site is cleansed. It is not necessary to use oxygen therapy for routine tracheostomy care in the home.

The nurse provides a brochure with discharge instructions for a client with a limited understanding of English. When asked if the client has any questions, the client responds in a different language. How does the nurse respond? "Would you like me to review the brochure with you again?" "An interpreter is available to assist you." "Please sign the education form to confirm your understanding." "Do you have a family member that can translate for you?"

"An interpreter is available to assist you." Rationale: The nurse recognizes that the client may or may not understand the teaching due to the response in a different language. The best response by the nurse would be to reach out for assistance after review of facility protocol with aid of an interpreter. Due to the language barrier, reviewing the brochure with the client may not be effective and not the best response. Having the client sign the patient education document to confirm understanding would not confirm client understanding. It is not acceptable to have another family member to be responsible for translating pertinent medical information.

The registered nurse (RN) is giving instructions to an unlicensed assistive personnel (UAP) regarding care activities for a new admission. Which directive provides the best information about assigned tasks? "Before 12 pm today, ambulate the client, and replace the sequential compression device (SCD) afterward." "You will need to frequently take an oral temperature for the client, and report the results to me immediately if it is too high." "Let me know how the new admission is doing, and tell me if you need any help." "Beginning at 8 am, empty the urinary catheter bag hourly, and write the amount and time on the whiteboard."

"Beginning at 8 am, empty the urinary catheter bag hourly, and write the amount and time on the whiteboard." Rationale: When assigning tasks, directions must be clear, concise, correct, and complete. Emptying the catheter bag and recording the amount hourly starting at 8 am meets these guidelines. The options related to ambulation and measuring the client's temperature are vague and incomplete. The option about the new admission is also vague and requires assessing the client; only RNs can assess clients.

The nurse is caring for a client who asks the nurse to use a treatment method that the client read about on the internet. Which of the following responses by the nurse would be most appropriate? "You shouldn't really use the internet for health care information. Most of it is incorrect." "Can you tell me more about the website where you read the information?" "I am willing to give it a try. Does it say what the success rate is for using this treatment?" "Why are you questioning your doctor's order? She is an expert in the field."

"Can you tell me more about the website where you read the information?" Rationale: Clients are internet savvy and often search the internet for medical information about their conditions and request information from others using social media. Since there is a lot of information on the internet, clients need the expertise of nurses and other health care providers to direct clients to information that is reliable, current, and evidence-based. Many health care organizations have a list of vetted mobile apps and internet sites clients can use. Asking the client an open-ended question about the origin of the information is a therapeutic communication approach and allows the nurse to determine the quality of the information and demonstrate respect for the client's autonomy. The other responses are non-therapeutic and will most likely make the client feel guilty for taking the initiative to learn more about their health.

The nurse manager is providing education to staff members on the importance of safeguarding client valuables during admission. Which statement by a staff member indicates the need for further teaching? "Clients are discouraged to leave valuables at home." "All valuables should be documented during the admission process." "Use of a hospital safe may be used to store client valuables until discharge." "Valuables should be properly labeled with client's name."

"Clients are discouraged to leave valuables at home." Rationale: Clients are encouraged to leave valuables at home. The admission process is used to record an inventory of personal belongings and valuables to ensure their return to the patient on discharge or transfer to another facility. Valuables, if kept with the client, should be placed in an appropriate place, such as a hospital safe. Valuables kept in hospital safe should be properly labeled with the client's name and description of the valuable.

A precepting nurse tells a graduate nurse, "A client may ask you how many years of experience you have." Which response by the graduate nurse indicates an understanding of client rights? "Clients do not need to know how much experience we have." "Clients should be redirected to focus on their treatment plan." "Clients have a right to know when a nurse is in training." "Clients can request a different provider at any time."

"Clients have a right to know when a nurse is in training." Rationale: A client has a right to know the identity and title of their healthcare providers. A graduate nurse has the knowledge competency that can be shared with the client. A client can request to know the experience of their healthcare providers. Ignoring a client's question does not build rapport. Clients have a right to express their concerns. However, requesting a new provider does not address the scenario.

The nurse needs to evaluate that an unlicensed assistive personnel (UAP) has completed delegated tasks. Which question by the nurse is most appropriate? "Did you obtain the client's blood glucose before breakfast?" "Why haven't you finished taking vital signs yet?" "Which clients are being discharged today?" "Was the client's blood pressure better this time?"

"Did you obtain the client's blood glucose before breakfast?" Rationale: The nurse should evaluate delegated tasks by ensuring that they have been completed at the appropriate time. In this case, asking if the UAP obtained a blood glucose before the client ate breakfast is appropriate. The UAP is not responsible for knowing which clients will be discharged or assessing if a client's status has improved or worsened. If the UAP is struggling to complete a task like vital signs, the nurse should step in and ask if the UAP needs help, but asking why they haven't finished is not an appropriate way to evaluate the task.

A nurse is reviewing information about advance directives with a client. The client states they do not want chest compressions and would like to give a do not resuscitate (DNR) directive. Which statement does the nurse make next? "Your wishes will be documented and respected." "Do you want other life-sustaining interventions?" "You should discuss your wishes with your family before deciding." "Are you sure this is the best decision to make?"

"Do you want other life-sustaining interventions?" Rationale: Chest compressions are a primary intervention of cardiopulmonary resuscitation (CPR). However, the nurse needs to obtain information about the client's wishes regarding other life-sustaining measures, such as dialysis, ventilation, and hydration. Telling the client their wishes will be respected is an important intervention. However, the nurse must first thoroughly explore the client's end of life wishes. Involving the family in end-of-life decisions should be the client's choice. The nurse's role in advance directives is to provide information, not question the client's decision. Chest compressions are a primary intervention of cardiopulmonary resuscitation (CPR). However, the nurse needs to obtain information about the client's wishes regarding other life-sustaining measures, such as dialysis, ventilation, and hydration. Telling the client their wishes will be respected is an important intervention. However, the nurse must first thoroughly explore the client's end of life wishes. Involving the family in end-of-life decisions should be the client's choice. The nurse's role in advance directives is to provide information, not question the client's decision.

The nurse is caring for a client who is being discharged home and the client's sister asks if she can have a copy of the client's chart. Which statement by the nurse is appropriate? "I will print out the full electronic medical record for you before discharge." "Documentation can be provided by the medical records department if the client requests." "Medical records cannot be accessed by anyone other than healthcare providers." "I can tell you anything that you would like to know, but I cannot give you the record."

"Documentation can be provided by the medical records department if the client requests." Rationale: The health insurance portability and accountability act (HIPAA) requires that clients' medical information remains confidential. The client is the only person that can request a copy of their medical information. Verbal sharing of private medical information also violates HIPAA if the client does not consent.

A new task force has been created at a hospital to address a recent increase in client falls. The first meeting is scheduled with members from several departments. Which statements by the nurse leader will increase meeting effectiveness? Select all that apply. "During our meeting today, we will share the information we have on client falls." "Today I will review the problem with client falls on our units." "Please introduce yourselves and your departments." "Let's discuss when we should meet next and what information we will bring." "This meeting can go as long as needed to get things done." "Let's focus on the number of client falls first and then we can talk about staffing."

"During our meeting today, we will share the information we have on client falls." "Please introduce yourselves and your departments." "Let's discuss when we should meet next and what information we will bring." "Let's focus on the number of client falls first and then we can talk about staffing." Rationale: The leader increases meeting effectiveness by not permitting one person to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (e.g. on a whiteboard) and then follow up with written minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect for team members' other commitments.

The nurse is administering ordered medications when the client refuses to take one of the pills. How should the nurse document this in the medical record? "Client was combative and would not take medications." "Education was provided but the client declined the medication." "Medication administration was not possible at this time." "Incident report completed after client would not take the medication."

"Education was provided but the client declined the medication." Rationale: The client has the right to refuse treatment (including scheduled medications) but the nurse needs to document that the client refused/declined the medication and that education was provided. In some cases the client needs a better understanding of the purpose of a medication to be comfortable taking it. There is not enough information in the question to determine if the client was combative, and there is no need to complete an incident report. Documenting that medication administration is not possible implies that the client was physically unable to take medications, therefore this is not the most appropriate statement.

The nurse is receiving a client into the pre-op holding area from the surgical unit. The client is scheduled for surgery in two hours. Which question is appropriate for the nurse to ask during the handoff? "Has the client received the prophylactic antibiotic?" "Has the informed consent document been signed?" "What is the duration of this procedure?" "Has the surgical site been marked?"

"Has the informed consent document been signed?" Rationale: Protocols for prophylactic antibiotics limit administration to within two hours of surgical incision. Therefore, the client should not have been given this medication at this time. The surgical nurse is more knowledgeable about the duration of procedures than the floor nurse, so this is not an appropriate question. The surgical site will be marked in the perioperative area as part of the universal protocol. Informed consent may have been signed prior to arrival in the preoperative area and is an essential element to the process. This is an appropriate question to ask.

A nurse is performing an assessment on a client post cardiopulmonary resuscitation for myocardial infarction. The client tells the nurse, "If this were to happen again, I would not want those chest compressions." How does the nurse respond? "Have you considered making a living will?" "Why would you refuse resuscitation efforts?" "You should not worry about this happening again." "It is important to focus on getting better right now."

"Have you considered making a living will?" Rationale: A living will is a type of advance directive that provides instructions for medical care when the client can no longer make decisions themselves. Refusal of chest compressions with cardiopulmonary resuscitation (CPR) can be included in a living will. "Why" questions do not provide therapeutic communication. Telling the client that a medical condition will not happen again is false reassurance. Telling the client to focus on getting better disregards the client's statement.

After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." Which response by the nurse is most appropriate? "He may be scared and taking it out on you. Let's talk to figure out what to do next." "He has a lot of problems. You need to have patience with him." "I will talk with him and try to figure out what to do or what the problem is." "Ignore him and get the rest of your work done. Someone else can care for him."

"He may be scared and taking it out on you. Let's talk to figure out what to do next." Rationale: The first response doesn't address the client's problems and belittles the UAP's feelings. The second response omits the UAP from the issue and excludes her from the plan of care. The third response encourages the UAP to ignore the problem, and it also doesn't fix the problem and excludes the UAP from the plan of care. The UAP should be encouraged to contribute to the plan of care, to help solve the problem. The client should also be encouraged to express their feelings. The nurse and UAP need to collaborate and make sure the client's needs are being met.

After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." Which response by the nurse is mostappropriate? "He may be scared and taking it out on you. Let's talk to figure out what to do next." "He has a lot of problems. You need to have patience with him." "I will talk with him and try to figure out what to do or what the problem is." "Ignore him and get the rest of your work done. Someone else can care for him."

"He may be scared and taking it out on you. Let's talk to figure out what to do next." Rationale: The first response doesn't address the client's problems and belittles the UAP's feelings. The second response omits the UAP from the issue and excludes her from the plan of care. The third response encourages the UAP to ignore the problem, and it also doesn't fix the problem and excludes the UAP from the plan of care. The UAP should be encouraged to contribute to the plan of care to help solve the problem. The client should also be encouraged to express their feelings. The nurse and UAP need to collaborate and make sure the client's needs are being met.

A nurse is providing care to a 15-year-old client who arrives at the clinic requesting an abortion. The client states that the parents are unaware of the pregnancy and would like to keep the treatment confidential. How does the nurse respond to the client's request? "We cannot perform this procedure without your parent's consent." "I will inform the healthcare provider of your wishes." "Are you aware of all of the risks involved with terminating your pregnancy?" "How did you arrive to the decision to terminate your pregnancy?"

"How did you arrive to the decision to terminate your pregnancy?" Rationale: The nurse must explore the adolescent client's ability to make their own decisions. Asking the client how they arrived at their decision assesses the presence, or lack of, social support systems. Telling the client that the procedure cannot be performed without the parent's consent will cause a loss of rapport with the client and may influence the client to terminate the pregnancy by other means. The healthcare provider should be informed of the client's wishes after the nurse considers the ethical implications of the client's request. Discussing the risks of terminating the pregnancy does not address the ethical concern and is not an independent nursing action.

The nurse has delegated a client's indwelling catheter care to the unlicensed assistive personnel (UAP). Which question by the nurse is appropriate to evaluate that the tasks were completed appropriately? "Did the client understand the education you provided?" "Do I need to replace the indwelling catheter?" "Did you assess the skin condition of the perineal area?" "How many milliliters of urine were emptied from the drainage bag?"

"How many milliliters of urine were emptied from the drainage bag?" Rationale: The nurse should gather feedback from the UAP about the task that includes, but is not limited to: when the task was completed, how much urine was emptied from the drainage bag, and if the UAP had any difficulty with the task. The UAP is not responsible for assessments, teaching, or clinical judgements about the client condition; therefore, these questions are not appropriate to evaluate completion of the task.

The nurse is providing staff training on client advocacy. Which of the following statements by a staff member indicates an understanding of advocacy? "I can advocate for my client by limiting their visitors when they are in severe pain" "Conducting a falls assessment is one way I can advocate for my client" "Advocating for my client may mean that I make decisions for them in their best interest" "Ensuring that my client gets the most aggressive medical treatment is part of my role as an advocate"

"I can advocate for my client by limiting their visitors when they are in severe pain" Rationale: The nurse's primary commitment is to the patient, so advocating for the client means promoting, advocating for, and protecting the rights, health, and safety of the patient. Limiting visitors is an example of advocacy. The nurse recognizes that the client is in pain; therefore, limiting the visitors allows for the nurse to advocate for additional measures to allow the client to rest and recover. Conducting a falls assessment is an example of nonmaleficence. Making decisions for your client because they don't know what is best is a form of paternalism. The nurse should promote self-determination (autonomy) and should encourage the client to participate in determining their own treatment plan.

A nurse is discussing advance directives with a client during an admission history. Which client statement indicates an understanding of a healthcare power of attorney? "The person I choose to make medical decisions for me must be someone within my immediate family." "I can appoint a person I trust to make medical decisions for me when I can no longer do so." "My healthcare proxy will make medical decisions for me anytime I am hospitalized." "Once I choose a person to be my power of attorney, I cannot select someone else."

"I can appoint a person I trust to make medical decisions for me when I can no longer do so." Rationale: A durable power of attorney appoints a healthcare proxy to make decisions for the client when they can no longer do so themselves. The proxy can be any competent adult the client chooses. A healthcare proxy will make decisions only when the client is no longer able to do so themselves. The choice of a healthcare proxy can be revoked or revised at any time by the client.

The nurse is performing discharge teaching for a client who is postoperative right below the knee amputation and will receive skilled nursing care at home. Which statement by the client would indicate a need for further teaching about the home care prescribed? "The dressing on my incision will be changed by the nurse." "I can ask the nurse to help me with cleaning my house." "My medication schedule will be reviewed by the nurse." "The nurse can monitor for signs of complications."

"I can ask the nurse to help me with cleaning my house." Rationale: Skilled nursing care focuses on providing the client treatments or interventions that are performed by a licensed nurse. Nurses who perform skilled care follow care plans developed based on the client's diagnosis or condition. Skilled nursing interventions include assessing for complications, changing dressings, administering and monitoring medications, and assist with some activities of daily living. A nurse performing skilled care does not provide services such as cleaning house or preparing meals.

The nurse is reviewing discharge instructions with a client who has a new prescription for a brand-name medication. The client states, "I don't think my insurance will cover that; I won't be able to take it." Which statement would be appropriate for this nurse to make? "The pharmacy can check with your insurance company if the medication is covered." "Your healthcare provider prescribed this specific medication for a reason." "You may need to pay for the medication to see if it is effective." "I can ask your healthcare provider if a generic medication is available."

"I can ask your healthcare provider if a generic medication is available." Rationale: The nurse recommending that the client ask the provider if the client can take the generic brand of the medication instead of the brand-name medication would be a cost-effective way of assisting this client to afford the medication. Nurses do not prescribe medications. Simply stating the client should contact a family member is not assisting the client with this problem. The health care provider ordered this drug because of symptom exacerbation. Telling the client to wait to see if the medication will be effective does not address the issue if the client cannot pay for it.

The nurse is preparing to administer newly prescribed simvastatin to a client who had a myocardial infarction. The client states, "I am not sure I want to take that medication; I heard it has side effects." Which statement by the nurse is appropriate? "You need this medication to prevent another myocardial infarction." "I can discuss with you the side effects that can occur with this medication." "I will inform your healthcare provider that you are refusing the medication." "You need to take the first dose to see if you will have any side effects."

"I can discuss with you the side effects that can occur with this medication." Rationale: Clients have the right to refuse treatment or procedures. Often the client will refuse because of concerns related to outcomes, such as side effects with medications. The nurse should recognize and respect the client's right to refuse but should also provide additional information or resources for the client to make the decision. Discussing side effects could provide the client with more information to make the decision. The nurse may need to inform the healthcare provider, but this does not address the client's concerns. Telling the client what would happen if they do not take the medication dismisses the client's concerns.

The nurse overhears two clients in the common area arguing over the television remote. Which statement by the nurse is most appropriate at this time? "If you two cannot get along, we will have to turn off the television." "Who had the television remote first?" "We cannot tolerate this behavior. Return to your rooms." "I can see that you all are unhappy. What is going on?"

"I can see that you all are unhappy. What is going on?" Rationale: When a client, family member, or staff member is upset, the nurse should ask them about their concerns to gather more information about the cause of their disagreement before taking action. Asking the clients who had the remote first, does not help to solve the disagreement. Telling the clients that they will need to return to their rooms or that the television will need to be turned off is not the most appropriate statement.

The nurse is developing discharge plans for a client who had a total knee arthroplasty and requires crutches for ambulation. Which statement by the client would indicate to the nurse the need for home health assistance? "My family will rotate driving me to appointments." "I have a chair in a walk-in shower." "I live in a two-story home." "My family will be gone during the day.

"I live in a two-story home." Rationale: It is recommended that the client premedicates prior to activities of daily living (ADL) to ease the pain that may be associated after a total knee arthroplasty (TKA). Post-medication treatment will not help the client endure the pain that may be associated with the ADL. This statement would require further review with the nurse. It is recommended that the client initially ask for assistance/support when bathing and use a shower chair. In addition, the client should perform hygiene in the morning instead of the evening when they have more energy.

The nurse is evaluating a licensed practical nurse's (LPN) ability to make appropriate decisions while performing assigned tasks. Which statement by the LPN indicates sound judgement? "I was planning to report the abnormal findings after I finish my other tasks." "I wanted to let you know that the client's heart rate is high." "I assumed you were taking vitals since I couldn't find the blood pressure cuff." "I will administer all of the client's oral medications later today."

"I wanted to let you know that the client's heart rate is high." Rationale: The LPN should report collected data to the registered nurse in a timely fashion, especially if there are abnormal findings. Delaying tasks until later in the day and stating that they did not complete a task because of an assumption shows poor judgement.

The nurse is precepting a new nurse employee and explains the standards of nursing documentation. Which statement by the new nurse employee indicates teaching was effective? "It is best to use general statements such as 'status unchanged' when writing client care notes." "I will summarize client comments in my own words to keep documentation concise." "I will leave blank spaces in the written notes section so staff can add notes later if needed." "I will document objective assessments and interventions at the time of client care."

"I will document objective assessments and interventions at the time of client care." Rationale: The medical record is a legal document. Documentation should include all steps of the nursing process. It must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags in a court of law and may indicate the nurse failed to meet the standards of care. The nurse should emphasize complete and accurate documentation at all times in the medical record. Nurses should avoid generalized statements. Specific information about the client should be included, along with complete descriptions of care provided. Nurses should not leave blank spaces in written notes sections. This leaves a place where someone could add incorrect information at a later time. Notes should be chronological. Client comments should be quoted, verbatim and placed in quotation marks when appropriate. Nurses should only enter objective information and objective descriptions of client behavior.

A client who is scheduled for surgery states to the nurse, "I have decided I do not want to have the surgery." Which statement by the nurse demonstrates advocacy? "That is a difficult decision; I am sure you made the best one." "If I were you, I would discuss it with your family first." "I will inform the healthcare provider of your decision." "You will need to sign forms to decline the surgery."

"I will inform the healthcare provider of your decision." Rationale: The role of the nurse is to advocate for the health, safety, and rights of a client. The client has the right to refuse treatments, including surgery. If a client has made the decision to refuse treatment, the nurse will advocate for the client by reporting the client's decision to the healthcare provider. The nurse may need to reinforce teaching or explore options with the client, but the nurse should not impose personal beliefs or belittle the client's decision.

A nurse is providing care to a client receiving chemotherapy for stage 4 colon cancer. The client tells the nurse, "I am tired of being in the hospital. I just want to stop treatment and go home." How does the nurse respond to the client's statement? "I will inform the healthcare team so we can discuss your options." "I know your medical condition is tough but you have to be strong." "How did you arrive to this difficult decision?" "Why do you want to give up on treatment?"

"I will inform the healthcare team so we can discuss your options." Rationale: The nurse's role in advocacy is to provide alternative options for treatment in collaboration with the healthcare team. The nurse will advocate for the client's right to make their own decisions. Acknowledging the client's condition is difficult provides empathy but does not address the client's statement. Questioning how and why the client made their decision does not promote autonomy.

A nurse is preparing to discharge a client with a diabetic foot ulcer. The client tells the nurse, "It's so hard for me to keep track of all my medications and treatments." How does the nurse best respond? "I will obtain a consult to social work to help you explore your options." "It is important for you to organize all your medications and treatments." "I understand it is difficult to manage such a complex disease." "Let's call your family to see who can assist you at home."

"I will obtain a consult to social work to help you explore your options." Rationale: A client with a diabetic foot ulcer indicates their disease is not being managed adequately. The client's concern can best be addressed by a social worker who can arrange community resources. Telling the client it is important to organize medications and treatments does not address the client's concern. Empathizing with the client is an important aspect of therapeutic communication; however, it does not address the issue. The nurse cannot assume the client's family will be capable in assisting the client with their diagnosis.

A client was recently discharged from a locked inpatient psychiatric facility. During a scheduled outpatient appointment, the client states to the nurse, "I'm afraid I am going to get sick again." Which response by the nurse is most likely to promote recovery? "You shouldn't fear a relapse because it can happen to anyone and we will be here to help you." "I will provide you with a bus pass and referral to a support group that will help you learn about managing your illness and medications." "If you take your medications exactly as your health care provider instructed, you won't get sick again." "I think you are doing well but you can call for an appointment with your health care provider if you think you need help."

"I will provide you with a bus pass and referral to a support group that will help you learn about managing your illness and medications." Rationale: Relapse prevention is a priority focus for clients recovering from an acute mental illness episode. Since education plus peer and community support rank high in helping prevent relapse, the priority is to refer the client to after-care and support groups. Additionally, since continuity of care involves access to care, the nurse should address the client's transportation needs by offering them a bus pass so they can attend these meetings. Continuing to take medications is important, but advice and reassurance without tangible follow up is not helpful to clients in early recovery from an acute event. Reassurance and referral to a health care provider may also be inadequate and does not demonstrate the nurse's concrete role in relapse prevention. Telling the client not to fear relapse and providing false reassurance is non-therapeutic.

The nurse is educating new nurses on the informed consent process. Which statement by the new nurse demonstrates an understanding of the nurse's role in informed consent? "I will sign the consent form as a witness to having seen the patient sign the form." "If the client has any questions, I will answer them before having the client sign the form." "If the healthcare provider is unavailable, I can conduct the informed consent discussion." "I do not need to assess the client's understanding of the procedure before having them sign the document."

"I will sign the consent form as a witness to having seen the patient sign the form." Rationale: As a nurse, you sign the consent form as a witness to having seen the patient sign the form, not as having obtained the consent yourself. Assess whether patients understand what they are signing and are acting voluntarily and report any concerns to the healthcare provider. Having patients describe in their own words what they understand they are consenting to is the best way to make sure that they understand.

A staff nurse reports to the nurse manager that an unlicensed assistive personnel (UAP) consistently does not perform assigned work duties. Which of these statements should the nurse manager make initially? "I will arrange for a conference with you, the UAP, and myself within the next week." "I can assure you that I will look into the matter in due time." "I would like for you to directly approach the UAP about the problem the next time it occurs." "I will add this concern to the agenda for the next unit meeting so all the staff can discuss it."

"I would like for you to directly approach the UAP about the problem the next time it occurs." Rationale: It is the nurse manager's role to help staff manage conflict among themselves. If the two staff members cannot resolve the issue, the next step would be to arrange for a private conference with the nurse manager and the staff involved in the conflict. Assuring the matter will be dealt with in due time does not address the issue directly. It would not be appropriate to discuss a conflict between two members in a group (staff meeting) setting as trust could break down and confidential information could be disclosed.

A nurse is precepting a graduate nurse on the oncology unit. The nurse notes a copy of a living will in a client's chart and asks the graduate nurse to define the meaning of the document. Which statement by the graduate nurse correctly defines a living will? "It is a legal document that expresses our client's wishes for medical treatment when they can no longer make those decisions themselves." "The document legally appoints another person to make medical decisions for our client should they be unable to do so." "The information in the document is a guideline for medical treatment but can be overridden by a provider's prescription." "Medical decisions outlined in the document are the client's wishes but do not protect healthcare providers from liability."

"It is a legal document that expresses our client's wishes for medical treatment when they can no longer make those decisions themselves." Rationale: A living will is a type of advance directive that expresses a client's wishes regarding their medical treatment in the event they can no longer make those decisions themselves. A living will is a legal document. Appointing another person to make medical decisions is a durable power of attorney. A living will is a legal document and must be honored by healthcare providers when providing medical treatment. Healthcare providers who follow a client's living will are protected from liability by state laws.

A nurse is performing an admission history on a client. When asked about medical history, the client tells the nurse, "I should not have to discuss my past illnesses with anyone." How does the nurse best respond to the client's statement? "It is important to know your medical history so we can make better decisions about your care." "Why don't you want to share information about your medical history?" "Would you feel more comfortable sharing your medical history at a later time?" "We cannot treat you if we don't know your past medical history."

"It is important to know your medical history so we can make better decisions about your care." Rationale: The client has a responsibility to share information about their past medical care with healthcare providers. A comprehensive history facilitates a patient care partnership. The nurse encourages the client to share information by providing education on the purpose of a health history. "Why" questions do not promote therapeutic communication and may cause the client to lose rapport with the nurse. Offering to collect the medical history at a later time does not address the client's hesitancy to provide information. The client can still receive treatment even if their medical history is unknown.

A nurse manager conducts a staff meeting on client self-determination. Which statement made by a staff member indicates further teaching on advocacy is required? "It is important to make ethical decisions for our clients." "A nurse can be involved in the client's decision making." "Clients should be presented with all possible treatment options." "A client can choose to delegate decisions about their medical care."

"It is important to make ethical decisions for our clients." Rationale: Client self-determination is the ability of the client to make their own decisions regarding their medical care. The nurse's role is to facilitate challenging decisions for the client, not make the decision for them. A nurse is involved in the client's decision making by providing and clarifying medical information and listening to the client's concerns. All treatment options should be presented to the client to allow them to make an informed decision about their medical care. The client has the right to delegate medical decisions to a person they trust.

A nurse is performing an admission history on a client. When asked about advance directives, the client states, "I want my partner to make medical decisions for me when I can no longer do so." How does the nurse respond to the client's statement? "Only your next of kin can make medical decisions for you." "It is important you prepare a legal durable power of attorney." "You should express your wishes in a living will." "It is best to choose someone who can objectively make decisions."

"It is important you prepare a legal durable power of attorney." Rationale: The nurse should encourage the client to prepare a legal document designating the partner as their power of attorney. Advance directives communicate a client's wishes and protect healthcare providers from liability when providing or withholding medical treatment. A health care proxy can be any competent adult the client chooses. A living will is a document that outlines the client's wishes for medical treatment when they can no longer do so themselves. The nurse's role in advance directives is to provide information, not to influence the client's decision in selecting a power of attorney.

A graduate nurse tells the charge nurse that a terminally ill client has verbalized wanting to end all medical treatment. The client's family is concerned with the client's statement. How does the charge nurse explain advocacy to the graduate nurse? "It is our duty to recognize the needs of both the client and their family." "We need to respect the wishes of our client only." "Always do what is medically necessary to keep the client healthy." "A terminally ill client should not make decisions without the family's consent."

"It is our duty to recognize the needs of both the client and their family." Rationale: The nurse's role as an advocate is to recognize and understand the needs of the client and their family. It is important for nurses to find solutions that benefit both the client and their loved ones. Although nurses advocate for the client's autonomy, they must also take the family's concern into consideration. Nurses should provide competent care but should also respect the client's autonomy regarding medical treatment. A terminally ill client who is coherent has the right to voice their own medical decisions.

The nurse is preparing a 25-year-old client for surgery and asks the client about an advance directive. The client states, "Why do you need to know that? I am young and this is supposed to be a minor surgery." Which response would be appropriate for the nurse to make? "It is required to ask if you have one and provide you with information if you don't, regardless of age or reason for hospitalization." "The hospital needs to be sure you have made the proper arrangements ahead of time in case anything was to happen to you." "Having an advanced directive in place will give the medical personnel the ability to make decisions for you." "The healthcare provider will need to have you complete the advanced directive before you have surgery."

"It is required to ask if you have one and provide you with information if you don't, regardless of age or reason for hospitalization." Rationale: The Patient Self-Determination Act requires all clients are asked if they have an advance directive in place to communicate the client's health care wishes. If the client does not have one, the information will be provided with assistance in how to fill one out. An advance directive or living will have to do with health care choices and designating someone to speak for you when you are not able regarding funeral arrangements. Healthcare providers are not given rights to express a client's end-of-life decisions in an advance directive or living will.

A nurse is providing care to a client with a gangrenous foot ulcer. The client states, "My healthcare provider told me the best course of treatment is to amputate the foot. I will not allow that." How does the nurse respond to the client's statement? "A gangrenous foot is dangerous. You should listen to the advice from your healthcare provider." "Try to rethink your decision. Refusing the treatment will worsen your condition." "This is not a choice you should make on your own. You should discuss this with your family." "It must be a difficult decision to make. Tell me more about what the treatment means to you."

"It must be a difficult decision to make. Tell me more about what the treatment means to you." Rationale: The nurse's role is to act as an advocate in the client's decision making. The nurse should explore the client's reasoning for refusing the course of treatment. Causing fear does not promote sensitive care. The nurse's role is to guide the client's decision, not influence their choice. Discussing the decision with family should be the client's choice. The nurse's role is to promote self-determination.

The nurse in a family practice office is teaching a client about establishing advance directives for health care. Which statement by the client indicates that further teaching is needed? "It is a legal document that becomes a part of my health care record." "My wishes for end-of-life treatment are stated in writing." "I will need to identify someone to be my health care proxy." "It will describe how my things should be divided between my family members."

"It will describe how my things should be divided between my family members." Rationale: An advance health care directive is also known as a living will. It is a legal document in which a person specifies their wishes concerning medical treatments at the end-of-life, when they are unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf. A living will does not expire; it remains in effect unless it is changed. A living will does not include information regarding assets or a person's estate.

A nurse is witnessing a healthcare provider tell a client with a gangrenous foot ulcer that the best course of treatment is a foot amputation. The client states, "I think I need to talk to my family before making such a big decision." Which statement does the nurse make? "It's important you make this decision independently." "Let's call your family so we can discuss your treatment." "Your condition may worsen without a prompt decision." "Tell me why it's important that you speak to your family."

"Let's call your family so we can discuss your treatment." Rationale: The nurse should respect the client's request to make a shared medical decision with their family. The nurse facilitates the interaction by contacting the client's family. The client does not have to make a medical decision independently if they are not prepared to do so. The nurse and healthcare provider should allow the client time to decide their treatment. The nurse should not question the client's request to make a shared medical decision. The client has a right to discuss their treatment with family.

The psychiatric nurse is caring for a client who was voluntarily admitted to the hospital 2 days ago for suicidal ideation. Today, the client states, "I demand to be released now!" Which response by the nurse is most appropriate? "Let's discuss your decision to leave and then we can prepare you for discharge." "You can be released only if you sign a no suicide contract before you leave." "You have a right to sign out as soon as we get the health care provider's discharge order." "You cannot be released because you are still at risk of being suicidal."

"Let's discuss your decision to leave and then we can prepare you for discharge." Rationale: Clients who are voluntarily admitted to the hospital have the right to demand and obtain release. Ideally clients should be given discharge instructions before they leave the hospital. However, clients have the right to sign themselves out of the hospital at any time, including against medical advice (AMA). The most appropriate response would be to engage the client in therapeutic communication and find out their current state of mind and risk for suicide. If the nurse felt that the client still represented a risk for suicide, a petition for an involuntary admission/hospitalization should be initiated. The other responses are not therapeutic or appropriate.

The psychiatric nurse is caring for a client who was voluntarily admitted to the hospital 2 days ago for suicidal ideation. Today, the client states, "I demand to be released now!" Which response by the nurse is most appropriate? "Let's discuss your decision to leave, and then we can prepare you for discharge." "You can be released only if you sign a no suicide contract before you leave." "You have a right to sign out as soon as we get the health care provider's discharge order." "You cannot be released because you are still at risk of being suicidal."

"Let's discuss your decision to leave, and then we can prepare you for discharge." Rationale: Clients who are voluntarily admitted to the hospital have the right to demand and obtain release. Ideally, clients should be given discharge instructions before they leave the hospital. However, clients have the right to sign themselves out of the hospital at any time, including against medical advice (AMA). The most appropriate response would be to engage the client in therapeutic communication and find out their current state of mind and risk for suicide. If the nurse felt that the client still represented a risk for suicide, a petition for an involuntary admission/hospitalization should be initiated. The other responses are not therapeutic or appropriate.

The nurse is preparing to discharge a client who has suffered full thickness burns to the chest and upper extremities. Which home care instructions should the nurse include as part of the discharge education to the client and family? Select all that apply. "Eat five to six small meals that are high-protein, low carbohydrate." "Avoid the use of emollients on affected skin and over scarred areas." "Arrange for physical therapy if you develop any problems with range of motion." "Notify the health care provider if you experience changes in sleep or mood." "Wear protective sleeves over your arms to prevent additional injury."

"Notify the health care provider if you experience changes in sleep or mood." "Wear protective sleeves over your arms to prevent additional injury." Rationale: Full thickness burns destroy multiple layers of skin, including their underlying structures (i.e blood vessels, nerves, sweat glands, etc). The overall goals of the rehabilitation phase with clients who have suffered these types of burns include injury prevention, prevention of loss of range of motion, and mental health wellness. The client should be instructed to use emollients on scarred skin to prevent it from becoming too dry, which can restrict movement. Hypermetabolism can last up to a year and requires the client to have a balanced diet that is high in both carbohydrates and protein. Wounds and scarred areas should be covered to prevent injury to the area while it heals. Physical therapy is a process that starts in the acute care setting and continues for months, and sometimes even years, after the start of therapy. Depression and anxiety are common and should be brought to the attention of the health care provider.

The nurse is preparing to discharge a client who has suffered full-thickness burns to the chest and upper extremities. Which home care instructions should the nurse include as part of the discharge education to the client and family? Select all that apply. "Eat five to six small meals that are high-protein, low carbohydrate." "Avoid the use of emollients on affected skin and over scarred areas." "Arrange for physical therapy if you develop any problems with range of motion." "Notify the health care provider if you experience changes in sleep or mood." "Wear protective sleeves over your arms to prevent additional injury."

"Notify the health care provider if you experience changes in sleep or mood." "Wear protective sleeves over your arms to prevent additional injury." Rationale: Full-thickness burns destroy multiple layers of skin, including their underlying structures (i.e blood vessels, nerves, sweat glands, etc). The overall goals of the rehabilitation phase with clients who have suffered these types of burns include injury prevention, prevention of loss of range of motion, and mental health wellness. The client should be instructed to use emollients on scarred skin to prevent it from becoming too dry, which can restrict movement. Hypermetabolism can last up to a year and requires the client to have a balanced diet that is high in both carbohydrates and protein. Wounds and scarred areas should be covered to prevent injury to the area while it heals. Physical therapy is a process that starts in the acute care setting and continues for months, and sometimes even years, after the start of therapy. Depression and anxiety are common and should be brought to the attention of the health care provider.

he nurse is discharging a client to an outpatient treatment program after hospitalization for acute depression. Which statement should the nurse include in the discharge instructions? "Attending outpatient therapy will continue to make you feel better." "You need to attend outpatient therapy to prevent readmission." "Your healthcare provider will be able to monitor you closely in outpatient therapy." "Outpatient therapy will allow you to return to your normal life activities.

"Outpatient therapy will allow you to return to your normal life activities. Rationale: Outpatient therapy allows the client to maintain treatment options (i.e., milieu therapy) but stay at home and resume normal life activities such as work. With the collaboration of a case manager and primary care provider, the transition from inpatient mental health service to outpatient services can be achieved and still provide the client with the services needed after stabilization. Outpatient therapy will assist the client in managing their condition; it is not a quick cure and may take time before the client feels the benefits. Inpatient treatment allows a healthcare provider to closely monitor a client.

The nurse manager is presenting quality improvement initiatives to staff nurses on how effectively use supplies on the unit. Which of the following statements indicates further teaching is needed on cost effective measures? "As long as we don't overstock supplies, we can cut costs." "Inventory of items we don't use should be monitored." "Supplies discharged with clients should be unlimited." "We should return unused supplies at the end of the shift."

"Supplies discharged with clients should be unlimited." Rationale: Effective nurse managers should be alert to the type and quantities of supplies used in their unit for cost effective care. Supplies discharged with clients should be limited, not unlimited, as well as limits to the practice of overstocking bedside supplies to reduce costs. Monitoring inventory of stock and obsolete or slow-moving stock also represents potential cost savings. Another way to cut supply cost and increase cost effective care is to remind staff to return unused supplies at the end of the shift.

A nurse is providing care to a client with stage 3 breast cancer. During the shift assessment, the client tells the nurse, "I have been given several treatment options. What do you think I should do?" How does the nurse respond to the client? "You should choose the treatment that will give you the best outcome." "Tell me how you feel about your treatment options." "Have you discussed the treatment options with your family?" "Who will be taking care of you after your treatment?"

"Tell me how you feel about your treatment options." Rationale: The nurse should encourage the client to verbalize their feelings about the treatment options. The nurse's role is to clarify concerns, provide information on the treatments, and help the client make their own decisions. Telling the client to choose the treatment that will give the best outcome does not allow the client to make their own choice and is unwanted advice. Asking the client if they have discussed treatment options with family and who will be taking care of them post-treatment does not focus on the client's self-determination.

The preoperative nurse is witnessing a client sign consents for surgery. The client states, "I am not sure if I should have the surgery." Which statement would be appropriate for the nurse to make? "You should talk to your family about your concerns." "I will let your healthcare provider know your feelings." "This is a hard decision for you to make." "Tell me more about what makes you think you do not want the surgery."

"Tell me more about what makes you think you do not want the surgery." Rationale: The nurse's role with informed consent is to the witness the client's signature of the consent. If the client expresses concerns, the nurse should gather more information about the client's feelings. The nurse should alleviate the client's anxiety by allowing the client to discuss their feelings and concerns. The nurse should notify the healthcare provider if the client refuses the surgery or has specific questions about the surgery.

The preoperative nurse is witnessing a client sign consents for surgery. The client states, "I am not sure if I should have the surgery." Which statement would be appropriate for the nurse to make? "Tell me more about what makes you think you do not want the surgery." "You should talk to your family about your concerns." "I will let your healthcare provider know your feelings." "This is a hard decision for you to make."

"Tell me more about what makes you think you do not want the surgery." Rationale: The nurse's role with informed consent is to the witness the client's signature of the consent. If the client expresses concerns, the nurse should gather more information about the client's feelings. The nurse should alleviate the client's anxiety by allowing the client to discuss their feelings and concerns. The nurse should notify the healthcare provider if the client refuses the surgery or has specific questions about the surgery.

A nurse is providing education on prescribed medications to a client diagnosed with anxiety. The client tells the nurse, "I will be managing my condition with alternative medicine." How does the nurse respond to the client's statement? "Alternative medicine is not proven to be effective." "Anxiety is best controlled with prescribed medication." "You should discuss this with your family before making a decision." "Tell me what you know about alternative medicine."

"Tell me what you know about alternative medicine." Rationale: The nurse's role as an advocate is to guide the client in making their own medical decisions. The nurse must ensure the client fully understands their options. Discrediting a treatment option does not promote a therapeutic relationship between the nurse and the client. Providing medical advice is not within the nurse's scope of practice. A family discussion is the client's choice. The nurse should promote client autonomy.

A nurse is providing care to a client post-myocardial infarction who has been prescribed a daily dose of aspirin. The client tells the nurse "I don't like taking medications. Do I have to take the aspirin everyday?" How does the nurse best respond to the client? "Taking new medications can be stressful." "You should follow the recommendations of your healthcare provider." "Tell me how you feel about your recent heart attack." "The aspirin can help prevent another cardiac event."

"The aspirin can help prevent another cardiac event." Rationale: The nurse's role is to provide the client with information on their treatment options. Stating the purpose of the medication will help the client make an informed decision about their care. Telling the client new medications are stressful does not help address the client's main concern. Telling the client they should follow the recommendations of the healthcare provider does not provide information about the treatment. The client's feelings about their medical condition does not address the client's concern regarding medications.

A nurse manager delivers an in-service to unit staff on reviewing the plan of care with clients. Which statement made by a nurse indicates an understanding of client rights? "The client can request a modification to their plan of care." "The plan of care should be reviewed with the client only when there are changes." "Consent for individual procedures is not necessary if a client agrees with the plan of care." "The treatment outlined in the plan of care is chosen by the client.

"The client can request a modification to their plan of care." Rationale: A nurse has a duty to review the plan of care with clients. Clients have the right to accept, refuse, or request a revision to their plan of care. The nurse communicates the client's request with the healthcare team. The plan of care should be reviewed with the client on an ongoing basis to ensure understanding of the medical treatment. Individual procedures, particularly if they are invasive, require additional written consent. The treatment plan is determined by the healthcare provider and discussed with the client.

A graduate nurse tells the precepting nurse that a client post total knee replacement has requested for physical therapy sessions to be performed earlier in the day. How will the precepting nurse tell the graduate nurse to address the client's request? "The client should be educated that physical therapy is best performed in the afternoon." "The physical therapists already have a set schedule for all their clients and cannot be changed." "Collaborate with physical therapy to modify the schedule to meet the client's wishes." "Inform the client it is important to continue the physical therapy as prescribed."

"The client should be educated that physical therapy is best performed in the afternoon." "Collaborate with physical therapy to modify the schedule to meet the client's wishes." Rationale: The client has the right to modify their plan of care if the outcome will continue to be safe and achieve the same goal. The nurse collaborates with the healthcare team to adjust activities that best meet the needs of the client. Unless there is a specific prescription for physical therapy timeframes, the nurse should respect the client's wishes to perform therapy at an earlier time. The nurse should not assume that physical therapy will be unable to accommodate the client's request. Telling the client it is important to continue physical therapy is not indicated because the client is not refusing to participate in their care.

The nurse is handing off care for a client on a postpartum unit at the end of the shift. Which of the following statements would be the most important to include in the report? "The client is not taking any time off from work after delivery. " "The client's perineal pain is best relieved in a side-lying position." "The client did not want to meet with the lactation consultant. " "The client had several visitors throughout the day. "

"The client's perineal pain is best relieved in a side-lying position." Rationale: When handing off care during shift report, the nurse should provide relevant and concise information about the client's diagnosis, change in status, pain relief strategies, intake/output and level of activity. Indicating that the client had visitors all day and that the client will not be taking time off from work are not the most important statements/information to include in the report. Although knowledge that the client did not want to meet with the lactation consultant may be important in care of this client, it is not as important as pain relief strategies for ongoing care planning.

The home health aide calls the nurse to report information about a client. Which information should be the highest priority for the nurse? "The family wants to discontinue the home meal service called Meals on Wheels. "The partner says the client has gotten slower when doing things every other day." "The urine in the urinary catheter bag is of a deeper amber, almost brown color." "The client reports not sleeping well for the past week."

"The urine in the urinary catheter bag is of a deeper amber, almost brown color." Rationale: Home health aides often report diverse client information to nurses through phone calls and electronic documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs that require immediate action and follow-up. The information of highest priority is the abnormal color of the urine from the client's urinary catheter which can be indicative of a urinary tract infection or other renal-urinary problem. The other options may need further assessment but are not the priority.

A nurse is discussing the plan of care with a family of a client with advanced dementia. The family tells the nurse they cannot provide adequate supervision for the client at home. How does the nurse respond? "There are long-term care facilities that can provide constant supervision." "The client only requires supervision during nighttime." "What is the reason the supervision cannot be provided?" "Is there anyone else that can provide supervision?"

"There are long-term care facilities that can provide constant supervision." Rationale: A client with advanced dementia requires constant supervision to ensure safety. The nurse should provide the family with options for community health care services. Clients with advanced dementia require supervision at all times. The nurse's duty is to provide community resources for the family and the client. The nurse does not need to question the family's inability to provide supervision. Asking if there is anyone else that can provide supervision does not guarantee the client will be safe at home at all times.

A nurse is discharging a client with newly diagnosed diabetes. The client tells the nurse "I can't afford the cost of insulin. I'll find another way to care for my condition." How does the nurse best respond to the client's statement? "There are resources available to assist you with these costs." "It is important that you take your insulin to manage your condition." "Tell me how you plan to manage your condition." "The cost of the medication varies depending on where you buy it."

"There are resources available to assist you with these costs." Rationale: The nurse's role as an advocate is to assist clients who have financial difficulties caring for their medical conditions. The nurse can refer the client to medication assistance programs for eligibility on low-cost medications. Emphasizing the importance of medical treatment and asking the client how they plan to manage their condition does not address the issue of financial difficulties. Telling the client that the cost of medication varies does not provide a resource for their financial concern.

A nurse is providing care to a client with cancer. The client tells the nurse, "I often feel alone. It's not easy to talk to my family about my illness." How does the nurse respond? "Would you like to talk more about your condition?" "Why do you think your family doesn't want to talk about your illness?" "There are several support groups in the community to help you cope." "It is not uncommon to feel alone given your diagnosis."

"There are several support groups in the community to help you cope." Rationale: The nurse recognizes the client's statement as an opportunity to provide information on community resources. Support groups can provide the client with an opportunity to share emotions and experiences with other people who have a similar diagnosis. The client's statement indicates an ongoing lack of social support systems. Asking the client to talk more about their condition does not address the long-term need. Questioning the client about the family's lack of support does not promote a client-centered, therapeutic relationship. Telling the client it is not uncommon to feel alone does not offer support.

The charge nurse is reviewing the client assignment with a staff nurse who is refusing to care for a client. Which statement by the nurse would indicate abandonment? "The client has a prescribed intervention that is against my religion." "I have not received the training for the care the client requires." "This client was not very nice to me when I provided care before." "The infection the client has can be harmful to me."

"This client was not very nice to me when I provided care before." Rationale: Client abandonment occurs when a nurse refuses to care for a client when a client-nurse relationship has been established. A nurse can refuse to care for a client if there is a religious issue, the nurse's health could be at risk, the nurse does not have adequate training to care for the client, or the nurse's judgment is impaired.

The nurse is preparing to administer prescribed baclofen to a client with multiple sclerosis who is experiencing bladder spasms. The client states, "I do not want to take that medication; it makes me sleepy." Which statement by the nurse would be most appropriate? "This medication is needed to stop the spasms." "We can discuss alternative interventions to treat the spasms." "You can discuss your concerns with your healthcare provider." "I can give the medication before bedtime."

"We can discuss alternative interventions to treat the spasms." Rationale: Clients who report unpleasant side effects of medications may be reluctant to continue taking the medications. Clients have the right to refuse treatments or procedures, and the nurse should recognize and respect the client's choice. When a client refuses a treatment, the nurse should discuss alternative options with the client. Telling the client to discuss the concerns with the healthcare provider does not address the need to treat the spasms. Explaining what the medication is for is important but does not address the client's refusal and dismisses their concerns. This medication is prescribed three times a day; a nurse cannot change the dosing times without discussing it with the healthcare provider.

The nurse receives a telephone call in an assisted living facility from a caller asking if a client was admitted to the facility. The caller identifies himself as a friend. Which nursing response is appropriate? "There is no one here by that name." "I will transfer your call to the client's room." "The client is being transferred here from another facility." "We do not provide that information without permission from the family."

"We do not provide that information without permission from the family." Rationale: The nurse needs to tell the caller that it is not proper to identify the client's location for confidentiality and privacy. The nurse should not transfer the telephone call, which would confirm the client's location, and the nurse should not identify if the client is not at the skilled nursing home so that confidentiality and privacy are maintained.

The nurse is caring for a client with an external fixator on the left leg. The unlicensed assistive personnel asks how to bathe the client with this device in place. Which response by the nurse is appropriate? "We need to provide meticulous care to all of the pins, so I will help with that part." "Please use normal saline and clean around all insertion points." "We will avoid touching the left leg altogether as it is immobilized." "We will need a bottle of chlorhexidine and some gauze for daily pin site cleansing."

"We need to provide meticulous care to all of the pins, so I will help with that part." Rationale: External fixation involves the surgical insertion of pins through the skin and soft tissues into and through the bone. A metal external frame is attached to these pins and is designed to hold the fracture in proper alignment to enable healing to occur. The disadvantage of an external fixator is an increased risk for pin site loosening and infection, which can lead to osteomyelitis. Wound care should occur at least daily and include the use of nonshedding gauze. Normal saline can be used, but wound care should be performed by the registered nurse so the assessment may occur. Chlorhexidine is too harsh for daily use and should be used weekly.

The nurse is caring for a client diagnosed with heart failure who has a prescription for a stat chest X-ray. The client is 1 hour post femoral cardiac catheterization, and the radiology technician has asked if the client can be turned to place the X-ray plate. Which response by the nurse would be appropriate? "Yes, the client can turn as long as the head of bed isn't lowered." "No, the X-ray will have to be rescheduled." "We need to turn the client carefully so that they do not bend the leg." "The client can be turned as long as the head of bed isn't raised above 45 degrees."

"We need to turn the client carefully so that they do not bend the leg." Rationale: After a femoral cardiac catheterization, the patient remains on bed rest for up to 6 hours with the affected leg straight and the head of the bed elevated no greater than 30°. For comfort, the patient may be turned from side to side with the affected extremity straight. When an X-ray needs to be completed, the client may be turned side to side for correct plate placement, but the head of the bed must remain <30 degrees elevated. Chest X-rays in clients with heart failure are important and should not be postponed.

The nurse is caring for a client currently living in a homeless shelter. During assessment, the nurse observes ecchymosis and swelling of the client's eye. When asked about the injury, the client states, "I get picked on, but I'm pretty tough." Which nursing response is appropriate? "What do you do to defend yourself?" "We will do what we can to protect you as required by law." "Nobody will bother you if you stay busy at the shelter. "I will recommend that you get a transfer to a safer shelter."

"We will do what we can to protect you as required by law." Rationale: Based on the assessment data given, the nurse recognizes that the vulnerable client may have been abused. A more detailed assessment would follow to rule out physiological or other causes. The nurse is mandated to report abuse in the vulnerable client. The other responses by the nurse do not provide safety for the client that is required by law.

A nurse is admitting a client to the medical unit. During the initial assessment, the client tells the nurse, "I don't want anyone knowing the reason I am in the hospital." How does the nurse respond to the client? "We will respect your decision to not disclose your medical information." "Visitors can be restricted while you are in the hospital." "It may be necessary to give information to your employer." "You will need to specify which medical information needs to remain confidential."

"We will respect your decision to not disclose your medical information." Rationale: Clients have a right to know their medical information will remain confidential. Clients must be provided with a notice of the facility's privacy practices upon admission. The client is not refusing visitors so a restriction is not indicated. Providing medical information to the client's employer is a breach of privacy. The client does not need to specify which medical information is to remain confidential. The client has a right to protect their information.

The hospice nurse is planning care for a new client with terminal cancer. Which statement by the nurse would best assess the client's needs? "How is your family coping with your diagnosis?" "Can you describe your spiritual beliefs?" "Do you have any questions about your care?" "What are your goals that you would like met?

"What are your goals that you would like met? Rationale: When a client is new to care, such as with hospice, the nurse should identify the client's needs by assessing for goals. The goals a client would like met will guide the nurse in developing a plan of care that focuses on interventions to meet the goals. Asking the questions about their care or describing spiritual beliefs are important but does not address the client's needs. While asking how the client's family is coping is important, it does not address the client's needs.

The nurse is providing an in-service on client confidentiality. Which statement requires further education on disclosure of client information? "If a child is being abused, this must be reported to authorities." "When a client tests positive for HIV, their partners will need to be notified." "If a client tests positive for smallpox, public health officials are notified." "A client's mental health information can only be shared with permission."

"When a client tests positive for HIV, their partners will need to be notified." Rationale: Confidential information may be lawfully disclosed about a client when the welfare of others is at stake. Confidentiality of HIV testing is required and may not be disclosed to the client's partners, that is the responsibility of the client to provide that information. This statement requires further education by the nurse. In cases of child abuse, this information must be legally disclosed to the proper authorities. Public health officials are notified with client information for any reportable condition (e.g., smallpox or COVID) to protect the welfare of the general public. A client's mental health information can only by shared with permission.

An unlicensed assistive personnel (UAP) who usually works on the pediatric unit is assigned to work on an adult medical-surgical unit. Which question should the charge nurse ask prior to assigning duties and tasks to the UAP? "When are you available for us to review your competency checklist?" "How long have you been a UAP?" "Do you think you will be comfortable caring for adult clients?" "What type of client care did you give in pediatrics?"

"When are you available for us to review your competency checklist?" Rationale: The UAP must be competent to accept assigned tasks. Using a checklist developed by the health care organization is the most objective and comprehensive way to determine the UAP's skill set. The length of time in a position and determining the comfort level of the UAP does not guarantee competency. Client care in pediatrics may not necessarily be relevant in an adult unit.

The nursing instructor observes a student nurse perform a urinary catheterization in the clinical setting. The student asks if there would be any legal implications if complications from the procedure occurred. What is the initial response by the nursing instructor to address this issue? "You are within legal scope of practice by following facility procedure." "Documentation of the procedure is supported by facility policy." "All caregivers can be summoned if there is legal concern." "The client consented to the urinary catheterization so there is no liability for complications."

"You are within legal scope of practice by following facility procedure." Rationale: The nursing student needs to recognize that by following facility policy and procedure guidelines under the direction of a nursing instructor that care is provided within legal scope of practice. This is the initial response by the nursing instructor. Completion of the procedure should include documentation in the medical or electronic record. Although all caregivers can be summoned if there is a legal concern, the best response is to directly address the student's concern regarding complications and working within scope of practice. The legal responsibilities are included in the client's agreement to the urinary catheterization.

The nurse is providing discharge instructions to a female client was diagnosed with factor v Leiden about newly prescribed warfarin. The client asks, "Should I continue taking oral contraceptive?" Which statement should the nurse make? "You will resume the oral contraceptive once you reach therapeutic levels with the warfarin." "You can take an oral contraceptive if it is estrogen." "You will need to discuss alternative birth control methods with your healthcare provider." "You can restart the oral contraceptive after you finish your warfarin prescription."

"You will need to discuss alternative birth control methods with your healthcare provider." Rationale: Factor v Leiden is an inherited condition where there is a mutation in a gene resulting in a hypercoagulable state. Clients diagnosed with factor v Leiden are at an increased risk of developing clots and will require life-long treatment with anticoagulants, such as warfarin. Estrogen based oral contraceptives increase the risk of developing clots and are contraindicated in clients with hypercoagulable disorders. The client should be instructed to discuss alternative birth control methods with their healthcare provider. Warfarin is dosed based on therapeutic levels, but does not indicate an oral contraceptive can be resumed.

The nurse is admitting a client to the outpatient surgery center. The client states, "I have never taken my wedding ring off and won't take it off now." What is the best response by the nurse? "You should have left your valuables at home." "The unit manager will hold your ring until you return from surgery." "Your ring will be safe in the locked cabinet with security." "Your ring can be taped to your finger prior to surgery."

"Your ring can be taped to your finger prior to surgery." Rationale: The nurse should recognize that there are circumstances when the client may not want to remove a valuable, such as a wedding ring. Depending on the surgery, some facilities allow a wedding band to be kept in place if it is secured to the finger with tape. The client is encouraged to leave all valuables at home or with a family member, although this should be stated to the client in a non-threatening therapeutic manner. It is not appropriate to lock the ring in the cabinet or give it to the unit manager to hold while the client is in surgery.

An 85-year-old client is admitted to a home health care agency following a hospitalization. The client needs assistance with activities of daily living (ADLs). During the admission process, the nurse develops a plan of care for this client. Place the following steps in the case management process in the correct order: 1. Identification of nursing problem 2. Complete referrals for assistance with ADLs 3. Reassessment of health status and ADL ability. 4. Evaluation of progress towards the client's home care goals. 5. Assessment of biophysical and sociocultural considerations. 1,5,2,4,3 5,1,2,3,4 2,1,5,3,4 2,5,1,4,3

5,1,2,3,4 5. Assessment of biophysical and sociocultural considerations. 1. Identification of nursing problem 2. Complete referrals for assistance with ADLs 3. Reassessment of health status and ADL ability. 4. Evaluation of progress towards the client's home care goals. Rationale: Case management is a collaborative process that follows the nursing process and assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs. When a client is admitted to a home health care agency, an assessment is conducted to ensure continuity of care between the hospital and the home health agency. The nurse should follow the nursing process and first assess the biophysical (i.e., physiologic) and sociocultural (i.e., interpersonal) considerations. Then the nurse can use this information to identify nursing problems. Once the problems are identified the nurse can make referrals as appropriate. After these referrals have been implemented, the nurse should reassess the client's health status and ADL abilities. Finally, the nurse should evaluate the client's progress toward their home care goals.

An internal disaster has occurred at the hospital. The nurse manager is reviewing the clients the charge nurse identified to be discharged. Which client identified by the charge nurse would require the nurse manager to intervene? A 24-year-old client in the second day of treatment for an overdose of acetaminophen A 75-year-old client admitted two days ago with an acute exacerbation of ulcerative colitis. A 17-year-old client diagnosed with sepsis 5 days ago and whose vital signs are within normal limits. A 40-year-old client known to have had an uncomplicated myocardial infarction 4 days ago

A 24-year-old client in the second day of treatment for an overdose of acetaminophen Rationale: An overdose of acetaminophen requires close observation for several days. Also, the duration of the course of treatment for the oral antidote N-acetylcysteine (NAC) is approximately 72 hours. NAC will protect the liver if given within 8 hours after an acute ingestion. When compared with the other clients, the client who overdosed on acetaminophen is the least stable and should not be discharged.

The charge nurse is reviewing assignments for the shift. The care team consists of a registered nurse (RN), a licensed practical nurse (LPN), and several unlicensed assistive personnel (UAP). Which of these clients would be most appropriate to assign to the RN? A 24-year-old newly diagnosed with type 1 diabetes mellitus who is scheduled for discharge A 60-year-old with a history of asthma and reported shortness of breath during the previous shift An 80-year-old who is postoperative day 1 following a right hip replacement A 56-year-old admitted with atrial fibrillation who converted to normal sinus rhythm without cardioversion

A 24-year-old newly diagnosed with type 1 diabetes mellitus who is scheduled for discharge Rationale: LPNs can care for clients whose conditions are not too complex or variable and if there is a low likelihood of an emergency. Also, RNs are responsible for providing client education; LPNs can only reinforce the plan of care and information already taught by the RN. Although the condition of the client scheduled for discharge would be considered "stable," the RN is responsible for discharge teaching and ensuring continuity of care after discharge; therefore, the 24-year-old client is most appropriate to assign to the RN.

The charge nurse of a hospital inpatient unit is asked to list the clients who can potentially be discharged. Which one of these clients is most appropriate for discharge? A 29-year-old client, diagnosed with type 1 diabetes since age 10, admitted 36 hours ago with diabetic ketoacidosis A 77-year-old client with an implantable cardiac defibrillator who was admitted yesterday after receiving multiple shocks A 16-year-old client who was admitted the previous evening with acetaminophen intoxication A 10-year-old pediatric client who was admitted earlier today with a diagnosis of suspected bacterial meningitis

A 29-year-old client, diagnosed with type 1 diabetes since age 10, admitted 36 hours ago with diabetic ketoacidosis Rationale: The client with type 1 diabetes is the only client with a chronic condition who has been treated for more than a day and whose condition is the most stable; therefore, this client is most appropriate for discharge. The other clients' conditions are either unstable and/or more acute.

The nurse is assigned to care for four clients in the emergency department. Which client should the nurse see first? A 22-year-old with acute asthma with episodes of bronchospasms A 34-year-old with a tension pneumothorax and tracheal deviation A 59-year-old with suspected viral pneumonia and atelectasis A 45-year-old with spontaneous pneumothorax and a respiratory rate of 28

A 34-year-old with a tension pneumothorax and tracheal deviation Rationale: Tension pneumothorax occurs when there is an accumulation of air under pressure in the pleural space. This causes compression of the lungs and decreases venous return to the heart. Tracheal deviation indicates a significant volume of air is trapped in the chest cavity, causing a mediastinal shift. This is a medical emergency. In tension pneumothorax, the tracheal deviation is away from the affected side. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side and cyanosis with a high risk of cardiac tamponade and cardiac arrest. This patient is the most critical and should be seen first.

The nurse is working with an unlicensed assistive person (UAP). Which newly admitted client would be most appropriate to assign to the UAP? An 81-year-old client diagnosed with severe depression A 47-year-old client diagnosed with obsessive-compulsive disorder A 15-year-old client diagnosed with dehydration and anorexia A 22-year-old client withdrawing from heroin, who is reporting seeing spidersThe nurse is working with an unlicensed assistive person (UAP).

A 47-year-old client diagnosed with obsessive-compulsive disorder Rationale: The unlicensed assistive person (UAP) can be assigned to a client with a chronic condition after an initial assessment is performed by the nurse. The client with obsessive-compulsive disorder (OCD) is most appropriate to assign to the UAP. This client has minimal risk of medical instability. The other clients will require closer monitoring by the nurse due to the potential for medical complications or increased safety concerns.

The charge nurse makes assignments for the nursing team, which consists of registered nurses (RNs) and licensed practical nurses (LPNs). Which client should be assigned to the LPN? A 65 year-old scheduled for discharge after angioplasty and stent placement A 49 year-old diagnosed with a new onset atrial fibrillation with a rapid ventricular response A 58 year-old with a history of hypertension, diagnosed with possible angina A 35 year-old who is 12 hours post cardiac catheterization

A 58 year-old with a history of hypertension, diagnosed with possible angina Rationale: LPNs should not be assigned clients that are unstable or require in-depth assessment and education. The LPN scope of practice does not include new admissions or the administration of blood products. For these options, the most stable client is the 58-year-old diagnosed with possible angina. An RN would need to provide education or frequent assessments on the other clients.

The nurse has received morning change of shift report about four assigned clients. Which of client should the nurse assess first? A 23-year-old client with a migraine headache and reports severe nausea A 45-year-old client scheduled for heart catherization in 30 minutes and needs preoperative teaching A 63-year-old with multiple myeloma who has an oral temperature of 101.8 F (38.8 C) and reports flank pain A 59-year-old with heart failure who requires assistance to the bathroom.

A 63-year-old with multiple myeloma who has an oral temperature of 101.8 F (38.8 C) and reports flank pain Rationale: When evaluating who to see first, the nurse should assess the client with any reported abnormal findings or change in condition. A client with multiple myeloma who has an elevated temperature should be seen first, as this could indicate an infection. The client with migraine reporting nausea and the client with heart failure report assistance to the bathroom are expected findings. The client who is preop for a heart catherization and requires teaching is stable and not the priority.

The charge nurse is making assignments for the upcoming shift. Which client would be most appropriate to assign to a licensed practical nurse (LPN)? A 76-year-old client who has cystitis, and is being treated with an indwelling urinary catheter. A 53-year old client who is confused since surgery 2 days ago. A 64-year-old client diagnosed with a possible transient ischemic attack who has neurological abnormalities. A 31-year-old client with multiple lacerations from a recent trauma and requires complex dressing changes.

A 76-year-old client who has cystitis, and is being treated with an indwelling urinary catheter. Rationale: The most stable client is the one diagnosed with cystitis. This client, who has predictable outcomes and minimal risk for complications, would be most appropriate to assign to the licensed practical nurse (LPN). The other clients require more complex care, specialized nursing knowledge, and skill or judgment that the registered nurse (RN) should provide.

The nurse is caring for a group of adult clients on a neurological unit in an acute care hospital. Which client should the nurse see first? A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home A client admitted with hepatic encephalopathy who has an elevated ammonia level A client admitted with a transient ischemic attack, who has a bubble study echocardiogram ordered A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64

A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home Rationale: After an unwitnessed fall, the nurse must consider the possibility of head injury. Due to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation, and an elevated ammonia level would not be unexpected for a client with hepatic encephalopathy. While the results of an echocardiogram with a bubble study would be relevant to the care of client with a transient ischemic attack (TIA), this client is not showing signs of a worsening condition requiring urgent assessment.

The nurse is caring for a group of adult clients on a neurological unit in an acute care hospital. Which client should the nurse see first? A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home A client admitted with hepatic encephalopathy who has an elevated ammonia level A client admitted with a transient ischemic attack who has a bubble study echocardiogram ordered A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64

A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home Rationale: After an unwitnessed fall, the nurse must consider the possibility of head injury. Due to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation, and an elevated ammonia level would not be unexpected for a client with hepatic encephalopathy. While the results of an echocardiogram with a bubble study would be relevant to the care of the client with a transient ischemic attack (TIA), this client is not showing signs of a worsening condition requiring urgent assessment.

The charge nurse in a critical care unit is making assignments for a group of nurses. One of the nurses usually works on an oncology unit but was "floated" to the critical care unit due to staffing needs. Which of the following clients is most appropriate to assign to the oncology nurse? A client on a continuous infusion of diltiazem A client 4 hours post-thoracic surgery A client on mechanical ventilation due to COVID-19 A client admitted with a pulmonary embolism

A client admitted with a pulmonary embolism Rationale: A nurse who is unfamiliar with clients typically found in a critical care unit should be assigned the most hemodynamically stable, least critically ill client. Although all of the clients require close monitoring, the client with the pulmonary embolism appears the most stable at this time. The other clients require specialized nursing skills and knowledge and should not be assigned to the oncology nurse.

The nurse is reviewing vital signs documented in the electronic health record for a group of clients. Based on this data, which client should the nurse see first? A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88 A client diagnosed with infective endocarditis who has a temperature of 101.8°F (39°C) A client diagnosed with heart failure who has a SpO2 of 82%

A client diagnosed with heart failure who has a SpO2 of 82% Rationale: The nurse should see the client with heart failure and a SpO2 of 82% first. The client with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82% indicates dangerously low oxygenation. An elevated temperature in a client with infective endocarditis is a clinically significant but not unexpected finding. A heart rate of 110 beats per minute in a client with atrial fibrillation is concerning, but it does not reflect the same life-threatening clinical finding as the low SpO2 in the client with heart failure. While elevated and of concern, a blood pressure of 152/88 is not as high of a priority for the nurse to address as a dangerously low oxygen level.

The nurse is reviewing vital signs documented in the electronic health record for a group of clients. Based on this data, which client should the nurse see first? A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute. A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88. A client diagnosed with infective endocarditis who has a temperature of 101.8°F (39°C). A client diagnosed with heart failure who has a SpO2 of 82%.

A client diagnosed with heart failure who has a SpO2 of 82%. Rationale: The nurse should see the client with heart failure and a SpO2 of 82% first. The client with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82% indicates dangerously low oxygenation. An elevated temperature in a client with infective endocarditis is a clinically significant but not unexpected finding. A heart rate of 110 beats per minute in a client with atrial fibrillation is concerning, but it does not reflect the same life-threatening clinical finding as the low SpO2 in the client with heart failure. While elevated and of concern, a blood pressure of 152/88 is not as high of a priority for the nurse to address as a dangerously low oxygen level.

The nurse is caring for a group of clients. Which situation would the nurse report to the social worker? A client is worried about how they will pay their bills after a motor vehicle crash. A client needs a repeat MRI on the same day as the scheduled discharge. Transportation needs to be scheduled for a client going to acute rehabilitation. The healthcare provider has prescribed early ambulation for a client after hip replacement surgery.

A client is worried about how they will pay their bills after a motor vehicle crash. Rationale: Sometimes a client needs specialized counseling from other healthcare professionals. Social workers assist clients and families in dealing with the social, emotional, and environmental factors that affect their well-being. They make referrals to appropriate community resources and aid with securing equipment and supplies, as well as with healthcare finances. Making sure a client has a test prior to discharge is the responsibility of the nurse. Transportation is usually scheduled by the case manager. Assistance with early ambulation can be obtained from physical therapists.

The nurse is performing chart audits for hospital-acquired conditions. Which condition that occurred during the hospital admission is a reportable event? A client left the hospital against medical advice. A client refused treatment. A client received the wrong type of blood transfusion. A client was discharged to the care of a family member.

A client received the wrong type of blood transfusion. Rationale: The National Quality Forum Serious Reportable Events in Healthcare identify specific events that happen to clients that may result in death, injury, or near miss. These events include surgery on the wrong part of the body, receiving the wrong type of blood transfusion, and development of a pressure ulcer. A client has the right to leave the hospital against medical advice and refuse treatment. A client can be discharged to the care of a family member.

The nurse on a post-surgical orthopedic unit receives nursing report on a group of adult clients. Which client should the nurse see first? A client who has not had a bowel movement since before surgery. A client who has some bloody drainage on the surgical dressing A client who has a respiratory rate of 8 breaths/min. A client whose reported pain level is 8 out of 10.

A client who has a respiratory rate of 8 breaths/min. Rationale: Post-surgical clients usually require opioid medications for adequate pain relief. These clients should be monitored for CNS and respiratory depression, a common side effect of this class of drugs. The client with a respiratory rate of 8 breaths per minute is likely experiencing this complication, therefore the nurse should see this client first. The other clients may also need to be seen, but their circumstances are expected and non-urgent.

The nurse is assuming care of assigned clients from the previous nurse. After receiving a report that all clients are stable, which of the following clients should the nurse plan to see first? A client who has a scheduled surgery in one hour A client who is ready to be discharged home A client who is four days postoperative after an appendectomy A client who is admitted for intravenous antibiotic therapy

A client who has a scheduled surgery in one hour Rationale: The client who has a surgery scheduled in one hour needs to be seen before other clients (assuming all are stable) because any preoperative assessments or medications must be completed before the client is taken for the procedure. This is the only client that has time-sensitive needs.

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A client who is scheduled for an abdominal X-ray and is awaiting transport A client who has a prescription for discharge and needs a dressing change A client who received oral pain medication 30 min ago and reports nausea A client who has a thoracic aneurysm and reports sudden back pain

A client who has a thoracic aneurysm and reports sudden back pain Rationale: When evaluating who to see first, the nurse should assess the client with abnormal findings that indicate the client is unstable. A client with a thoracic aneurysm reporting back pain should be seen first, which could indicate that the aneurysm is rupturing. The clients who are waiting for an X-ray, just received pain medication, and have a prescription for discharge are stable and not the priority.

A nurse receives report on a couple of clients who require total care. After performing shift assessments, which client would benefit from a care plan revision? A client who states they urinated on the bedsheets A client who is able to tolerate a high-Fowler's position A client who is able to brush their own teeth A client who uses the call bell to request pain medication

A client who is able to brush their own teeth Rationale: A client who is able to perform self-care activities is no longer considered total care. The nurse should discuss the client's abilities with the healthcare team to promote independence. A client who is incontinent cannot provide for their own hygiene needs. A client who is able to tolerate a high-Fowler's position does not indicate they can reposition themselves. A total care client still has the ability to feel pain. Requesting pain medication does not indicate independence with self-care activities.

The nurse from a women's wellness health clinic is temporarily assigned to an adult medical unit. Which of these client assignments would be most appropriate for this nurse? A client admitted for a barium swallow after a transient ischemic attack. A client who was in a motor vehicle accident who has an external fixation device on their leg A newly admitted client with a diagnosis of pancreatic cancer and severe dehydration A newly diagnosed client with type 2 diabetes mellitus who is learning about foot care

A client who was in a motor vehicle accident who has an external fixation device on their leg Rationale: The nurse from the wellness clinic should be assigned to the client with the leg fracture. This client is the most stable and providing care for this client has predictable outcomes. The contraindications in the other clients are: "newly diagnosed," "after a transient ischemic attack (TIA)," and "newly admitted...severe dehydration." All of these clients have a health concern that's less stable than the client who has a stable fracture.

The registered nurse (RN) is making staffing assignments at the start of a new shift. Which of the following clients is appropriate for the RN to assign to the licensed practical nurse (LPN)? An older adult client with a diagnosis of hypertension and self-reported nonadherence to their medication regimen. A preoperative client with a history of asthma awaiting an adrenalectomy. A client with a diagnosis of peripheral vascular disease (PVD) with an ulceration of the lower leg. A new admission with a history of diagnosis of transient ischemic attacks and syncope.

A client with a diagnosis of peripheral vascular disease (PVD) with an ulceration of the lower leg. Rationale: The registered nurse is responsible for the management of the patient care. The licensed practical nurse (LPN) has a scope of practice that limits some of the actions of the LPN. The client with PVD is stable with a chronic condition and is appropriate to assign to an LPN. The preoperative client will likely require teaching, which is in the scope of the RN. The client with TIAs and syncope, as well as the client with hypertension are potentially unstable and should not be assigned to the LPN.

The nurse receives report on the following four clients. Which client should the nurse see first? A client with acute urinary retention who has orders to insert an indwelling catheter A client with a stage 3 pressure ulcer who is due for a scheduled dressing change A client who had a hysterectomy performed 12 hours ago and is nauseous A client who had an above the knee amputation and has a temperature of 101.3°F (38.5°C)

A client with acute urinary retention who has orders to insert an indwelling catheter Rationale: The client with acute urinary retention should be seen first. The client needs to have an indwelling urinary catheter inserted to relieve bladder distention. If acute urinary retention is left untreated, then bladder damage, incontinence or kidney failure can result. The other client problems (e.g., nausea, fever and dressing change) are of lower importance.

A nurse is providing care to several post-surgical clients. Which client would benefit the most from a referral to occupational therapy? An accountant who had an internal fixation of the ankle A waitress who had a laparoscopic cholecystectomy A teacher who had an incision and debridement to an arm wound A data entry specialist who had a carpal tunnel release

A data entry specialist who had a carpal tunnel release Rationale: The primary job function of a data entry specialist is to type on a computer. A client with a carpal tunnel release would benefit from occupational therapy to regain mobility of the wrists and hands. The job duties associated with being an accountant do not require frequent ambulation. Therapy for ambulation is more closely associated with physical therapy. A laparoscopic cholecystectomy is typically an outpatient procedure with limited restrictions. An incision and debridement of an arm wound does not restrict the mobility required for a teaching profession.

The emergency room nurse is triaging several clients. Which client should be seen by the health care provider first? A young adult client who sustained a singed beard, eyebrows and hair from a camp fire A 2-month-old infant who has bulging fontanels and is crying loudly An older adult client with complaints of frequent liquid stools A middle-aged client with intermittent epigastric pain after eating

A young adult client who sustained a singed beard, eyebrows and hair from a camp fire Rationale: The nurse should use the airway-breathing-circulation (ABC) prioritization approach to determine which client should be seen first. The client who suffered singed facial hair from a camp fire is at highest risk for airway problems due to the high likelihood of inhalation injury to the upper and lower airway. This injury is caused by the inhalation of hot air, steam, or smoke. The singed facial hair is a telltale sign of a potential inhalation injury. Pulmonary edema tends to appear around 12 to 48 hours after the injury and manifests as acute respiratory distress syndrome (ARDS). None of the other clients are exhibiting symptoms that pertain to the airway or breathing; therefore, the young adult client should be seen first.

A nurse is reviewing the care plan of a client post total hip replacement 72 hours ago. The current goal is for the client to ambulate 50 feet with the use of a walker by post operative day 3. During the physical therapy session, the client is able to ambulate only 35 feet. Which revision will the nurse make to the client's care plan? Choosing an alternate nursing diagnosis Adjusting the time criteria Changing the assistive device for ambulation Decreasing the distance goal

Adjusting the time criteria Rationale: The nurse should adjust the time criteria for the current outcome statement. The client is able to ambulate, but it may be too soon to accomplish the goal set by the initial care plan. The nursing diagnosis does not need to be modified. Mobility is a priority for a client with a total hip replacement. Changing the assistive device for ambulation is not required. The client is able to ambulate with the current assistive device. A distance of 50 feet is a realistic goal. The client has achieved a significant distance for the current time criteria.

A nurse initiates a rapid response for a client experiencing diaphoresis, heart palpitations, and chest pain. Which priority action will the nurse perform before the critical care team arrives? Initiate an additional intravenous access line Request a STAT electrocardiogram Ensure the client receives pain medication Administer supplemental oxygen to the client

Administer supplemental oxygen to the client Rationale: The nurse should administer supplemental oxygen to the client experiencing signs of a myocardial infarction. The priority action is to maintain adequate perfusion. Maintaining intravenous access is important; however, initiating an additional IV line indicates the client already has a patent access line. An electrocardiogram will likely be requested when the critical care team arrives. The nurse's priority is to maintain the client's perfusion. Pain management is an important intervention; however, the nurse must first ensure the client has adequate oxygenation and perfusion to vital organs.

The nurse is planning care for a client with pancreatitis who has a prescription for intermittent nasogastric suction. Which intervention is the priority for the nurse to include in the plan of care? Administer the prescribed intravenous (IV) dose of ondansetron Encourage supine position to limit gastric losses Resume high-fat diet based on client tolerance Administer prescribed oral opioid analgesics

Administer the prescribed intravenous (IV) dose of ondansetron Rationale: The priority intervention of the nurse to include in the plan of care for a client prescribed nasogastric suction for severe nausea and vomiting is the administration of ondansetron intravenously as prescribed. The client should be placed in a side-lying position for comfort and to decrease the risk of aspiration. When diet is resumed, oral intake should be started slowly with small, frequent, high-carbohydrate meals. A high-fat diet will exacerbate acute pancreatitis. The client will not be able to receive oral opioid analgesia with nasogastric suction.

The registered nurse is caring for a client who is diagnosed with type II diabetes and has impaired mobility. Which of the following actions can be delegated to the licensed practical/vocational nurse? Develop the plan of care. Teach the client about symptoms of hypoglycemia. Complete a comprehensive head to toe assessment. Administer the prescribed pramlintide subcutaneously.

Administer the prescribed pramlintide subcutaneously. Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. LPNs/LVNs can administer subcutaneous medications.

The registered nurse is caring for a client who had a cardiac catheterization. Which action is appropriate to delegate to the licensed practical nurse (LPN/LVN)? Performing the initial assessment of the catheter insertion site Teaching the client about the post-procedure plan of care Administering the scheduled lipid-lowering medication Evaluating the effectiveness of the nursing interventions

Administering the scheduled lipid-lowering medication Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated should be based on the training and competence of the individual accepting the delegation.

The nurse is caring for a client who is 6 hours post- laparoscopic hysterectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? Check the abdominal wound for bleeding Increase the rate of the IV fluid as prescribed Ambulate the client to the bathroom as needed Auscultate the breath sounds in all lobes

Ambulate the client to the bathroom as needed Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. Assisting clients to the bathroom is in the scope of routine care, activities, and procedures that are performed by a UAP.

The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU). What is one of the best reasons for having access to an eICU? Less staff is needed on site when a remote eICU is available Clients can ask the intensivist for a second opinion An ICU nurse and intensivist remotely monitor ICU clients around the clock An ICU nurse is on-call to answer questions when needed

An ICU nurse and intensivist remotely monitor ICU clients around the clock Rationale: Using cameras, microphones, and high-speed computer data lines, the eICU involves having an experienced ICU nurse and practicing intensivist monitoring ICU clients in remote locations around the clock. The eICU does not change the ratio of nurses to clients at the bedside, but it does make the nurse's bedside time more productive and assistance from their remote colleagues is only a push button away.

The nurse is obtaining the health history for a client with the help of an interpreter. To promote clear communication with the client, which of these actions is appropriate for the nurse to use? Arrange the setting so the interpreter and client can be easily seen by the nurse Provide the interpreter with a list of questions to address and stay with the client Ask the client to speak slowly and clearly with pauses after every statement Look at the interpreter when communicating the needed questions

Arrange the setting so the interpreter and client can be easily seen by the nurse Rationale: The nurse should look directly at the client when speaking to the client with an interpreter. The nurse should observe the client for nonverbal cues while the client answers the questions. This is best achieved by arranging the setting so the nurse, interpreter and client can easily see each other. It is important to note that the nurse is interviewing the client. It would be inappropriate for the nurse to write a list of questions for the interpreter. Additionally, the client should speak in their normal tone and speed for the interpreter.

The nurse needs to evaluate that tasks delegated by the licensed practical nurse (LPN) were completed effectively. Which action by the nurse is most appropriate? Verify the provider's prescriptions for each task. Ask the LPN for feedback about the tasks. Observe the completion of all delegated tasks. Complete a comprehensive assessment.

Ask the LPN for feedback about the tasks. Rationale: To ensure that a task has been completed appropriately, the nurse should ask the LPN for feedback about those tasks. This allows the nurse to gain insight about the task(s) to evaluate that they were completed. Observing all tasks that have been delegated is not an effective way to evaluate completion because the nurse would be spending the same amount of time observing that it would take for them to complete the task themselves. Verifying the provider's prescription does not evaluate tasks, and completing a comprehensive assessment is important but does not necessarily provide data about the delegated tasks.

A 65-year-old male client diagnosed with prostate cancer rates his pain level at 6 on a 0 to 10 scale. The client refuses all pain medication except for acetaminophen, which does not relieve his pain. Which action should the nurse take first? Talk with the client's family about the situation. Ask the client further about the refusal of pain medication. Report the situation to the health care provider. Document the situation in the client's medical record.

Ask the client further about the refusal of pain medication. Rationale: Beliefs regarding pain are determined by sociocultural norms, including age and gender. Nurses should investigate the meaning of pain to each client within a cultural explanatory framework. Astute observations and careful assessments must be completed to determine the level of pain the client is experiencing. Any action should be documented in the client's record, but this should occur after first speaking to the client. Should the client continue to have pain, the nurse may need to speak to the family and the health care provider.

A client with stable angina requests to be discharged from the emergency department. The healthcare provider explains the risks of not receiving medical treatment and refuses to discharge the client. Which action does the nurse perform next? Encourage the healthcare provider to discharge the client Contact the nurse manager to speak with the client Ask the client to sign an against medical advice form Request an unlicensed assistive personnel to escort the client out of the facility

Ask the client to sign an against medical advice form Rationale: Alert, stable, and mentally competent clients have the right to refuse medical care. The nurse must ensure the client understands the risks of refusing medical care and ask the client to sign an against medical advice form before exiting the facility. The nurse respects the client's wishes but does advocate for an unsafe discharge. Escalation of the situation to a nurse manager is not indicated if the healthcare provider has explained the risks to a stable, mentally competent client. A client can be escorted out of the facility if necessary after signing an against medical advice form.

Upon walking into a client's room, the nurse observes a family member yelling at the unlicensed assistive personnel. Which action by the nurse is most appropriate? Ask the family member to discuss their concerns with you Call facility security to handle the situation Come back to the client's room at a later time Tell the family member that they need to leave

Ask the family member to discuss their concerns with you Rationale: When a client, family member, or staff member is upset, the most appropriate action by the nurse is to try to deescalate the situation by listening to the person's concerns. Depending on what those concerns are, the nurse can choose their actions more appropriately. Calling security or asking the family member to leave may be necessary if the nurse is unable to deescalate and address the situation. Coming back at a later time does not address the conflict and potentially allows the situation to escalate further.

The nurse witnesses a staff member visibly upset after a conversation with a provider. Which action by the nurse is appropriate at this time? Avoid conversation with the staff member until they are no longer upset Offer to take the staff member's clients while they take a break Tell the staff member that it eventually gets easier to deal with providers Ask the staff member what has made them upset

Ask the staff member what has made them upset Rationale: The nurse should ask the staff member if they are alright and gather more information about what happened. Depending on what has caused the staff member to be upset, the nurse can choose their response more appropriately. Avoiding the staff member or telling them that they should take a break does not address the situation. Telling the staff member that it gets easier implies that whatever upset the staff member is normal.

The charge nurse observes staff members arguing about their client assignments. Which action by the charge nurse is appropriate at this time? Let the staff members work it out amongst themselves Ask the staff members about their concerns Adjust the staff members' client assignments Notify management about the staff members' incivility

Ask the staff members about their concerns Rationale: The nurse should ask the staff member about their concerns to gather more information about the cause of their disagreement before making any changes. Allowing the staff members to work it out amongst themselves might be appropriate if they were not already having an argument. There is not enough information presented to determine if incivility is taking place.

A 72-year-old client who has osteomyelitis requires a six-week course of intravenous antibiotics. In planning for home care, what is the priority approach by the nurse? Determine if there are adequate handwashing facilities in the home Investigate the client's insurance coverage for home IV antibiotic therapy Assess the client's ability to participate in self-care and/or the reliability of a caregiver Select the appropriate venous access device for the long-term IV medication

Assess the client's ability to participate in self-care and/or the reliability of a caregiver Rationale: The cognitive ability of the client, as well as the availability and reliability of a caregiver, must be assessed to determine if home care is a feasible option. The other approaches are correct and would be pursued after this initial approach.

The emergency room nurse is caring for a client with suspected domestic abuse. What will the nurse do to assist the client first? Assess the client's environment for safety prior to discharge Provide the client with a map to local shelters Direct the client to legal services in the community Refer the client to a psychological counseling service

Assess the client's environment for safety prior to discharge Rationale: Safety is the priority intervention for the client suspected of domestic violence. A wide range of resources are available to meet the needs of victims of violence. Nurses should be prepared to help the woman take advantage of these opportunities. Services will vary by community but might include psychological counseling, legal advice, social services, crisis services, support groups, hotlines, housing, vocational training, and other community-based referrals. The client should be given the National Domestic Violence hotline number: (800) 799-7233.

The nurse is caring for a client with a history of chronic pain who reports inadequate pain relief from oral analgesics. The client states "I just can't do the things I used to." Which action by the nurse would be most appropriate? Obtain a prescription for a higher dose from the health care provider Ask the health care provider to change the analgesic route to IV Assess the client's knowledge of complementary alternative medicine Refer the client to a pain specialist

Assess the client's knowledge of complementary alternative medicine Rationale: Client independence is best achieved by assessing the client's knowledge of complementary alternative medicine. This action supports self-care and client participation. An increased dose as well as an alternate route of administration (oral to intravenous) may provide temporary relief but could increase side effects that could limit a client's independence. Referrals may be needed but do not support client measures to manage pain and self-care independently.

The nurse is caring for a client with an intravenous (IV) infusion for pain control. Which of the following can the nurse delegate to the unlicensed assistive person (UAP)? Check the IV site for drainage and loosen tape when in the room. Readjust the rate on the pump by 2 mL/minute. Monitor the client for the degree of pain relief. Assist the client with ambulation after supervising a gown change.

Assist the client with ambulation after supervising a gown change. Rationale: When giving assignments to a UAP, the nurse should communicate clearly and specifically what the task is, what should be reported to the nurse and when it should be reported. Implementation of routine tasks with expected outcomes should be delegated to UAPs. The other options are actions that PNs or RNs could do.

The nurse is planning the daily care for assigned clients. Which of the following tasks can be delegated to the unlicensed assistive personnel? Assessing a client's surgical wound Assisting a client with ambulation Removing a peripheral IV Documenting medication administration

Assisting a client with ambulation Rationale: An unlicensed assistive personnel (UAP) cannot assess a client, remove invasive lines (such as an indwelling catheter or IV), or document tasks in the medical record that are out of their scope of practice (medication administration). It is appropriate to ask for a UAP to assist a client with ambulation.

The nurse is caring for a group of clients with neurological disorders. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? Teaching Crede's maneuver to a client needing to void Administering tube feeding to a quadriplegic client Assisting with bowel training by placing the client on the bedside commode Observing the client for correct self-catheterization

Assisting with bowel training by placing the client on the bedside commode Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they may not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. The UAP can assist the client to the bedside commode. All other tasks should be completed by an individual with licensure.

The nurse manager of an emergency department is planning for the arrival of a high number of clients due to a mass casualty event nearby. Which style of leadership would be most appropriate under these circumstances? Apply an integrative leadership approach Assume an autocratic, decision-making role Adopt a transformational, non-directive approach Engage in collaborative practice

Assume an autocratic, decision-making role Rationale: A manager should change their leadership style to fit the circumstances. During an emergency or crisis situation, decisions will have to be made fast and the manager will not have time to solicit input from staff; therefore, an autocratic or authoritarian leadership style is most appropriate in this situation. The other leadership styles would be appropriate in different situations, but not an emergency or crisis situation.

A graduate nurse and an experienced nurse are providing care to a client who refuses to be discharged to a skilled nursing facility. The client's family does not feel capable of caring for the client at home. How will the nurse encourage the graduate nurse to practice advocacy? By telling the graduate nurse the client's wishes must be followed By instructing the graduate nurse to obtain a social work consult for the client By encouraging the graduate nurse to change the client's decision By guiding the graduate nurse to convince the family to take the client home

By instructing the graduate nurse to obtain a social work consult for the client Rationale: Using available resources to help clients make a medical decision is part of nurse advocacy. Discharge conflicts between clients and their family require additional resources, such as a social worker or case manager. The client's decision conflicts with the family's ability to care for the client at home. Additional resources are necessary. A nurse's role is not to change a client's or family's decision. A nurse advocate provides all necessary resources to clients and their family, so they can make a joint medical decision.

The charge nurse in a long-term care facility is reviewing assignments for the shift. Which task is appropriate to delegate to a certified nursing assistant (CNA)? Provide oral suctioning for an unresponsive client Apply a dry dressing to a skin tear Calculate and record intake and output Teach another CNA how to perform passive range-of-motion exercises

Calculate and record intake and output Rationale: CNAs are considered unlicensed assistive personnel (UAP) and are trained to perform a number of tasks or basic nursing skills, including calculating and recording intake and output. Although CNAs can wash and apply emollients on skin, they should not apply dressings. A CNA should not suction a client's mouth. Although CNAs can perform passive range-of-motion exercises, they cannot teach others how to do this.

The nurse is caring for a client who is recovering from a hip replacement. The client has verbalized concerns about scheduling physical therapy once they are discharged. Which member of the healthcare team should the nurse collaborate with to address this concern? Physical therapist Social worker Case manager Visiting nurse

Case manager Rationale: The case manager will work with outside healthcare providers to plan for the transition from inpatient to outpatient rehabilitation services. The social worker's role is to help clients find community resources outside of healthcare services. A visiting nurse provides care in the home but not physical therapy. The nurse would not collaborate with a visiting nurse to schedule physical therapy. Hospital-based physical therapists do not schedule outpatient services.

A nurse is providing care to a client with a traumatic brain injury. The nurse reviews the client's living will and notes there is no indication for artificial nutrition and hydration. Which action does the nurse perform next? Checks the client's record for a healthcare power of attorney Contacts the healthcare provider to prescribe artificial nutrition Calls the client's next of kin to inform them of the client's nutritional needs Provides the client with comfort care only

Checks the client's record for a healthcare power of attorney Rationale: Any medical decisions not indicated on a client's living will are transferred to a healthcare power of attorney, if available. The client's record is to be reviewed by the nurse to confirm the presence of an additional advance directive. Healthcare providers may prescribe medical treatment as appropriate. However, the nurse should first check the client's record for an advance directive. The next of kin can help guide the client's care if no healthcare power of attorney has been designated in an advance directive. Comfort care is only one section of a living will and is designated for terminal conditions.

The nurse is reviewing the interventions in the plan of care for a client admitted with pneumonia. Which action implemented by the nurse would be documented as an indirect care intervention? Auscultating breath sounds Chest physiotherapy Measuring client's intake Closing the door to the client's room

Closing the door to the client's room Rationale: Nursing interventions are treatments based on clinical judgment and knowledge by the nurse and can either be direct or indirect. A direct care intervention refers to actions by the nurse that are performed with interaction with the client. Indirect care interventions are performed away from the client but the outcomes will benefit the client, such as managing the client environment.

The nurse is caring for a group of surgical clients with multiple tasks that need to be completed. One of the clients is refusing to ambulate. What action is should the nurse take? Delegate the ambulation to the unlicensed assistive personnel Collaborate with the client to determine the barriers to ambulation Request assistance from other staff members to ambulate the client Document that the client refused care

Collaborate with the client to determine the barriers to ambulation Rationale: The client may be refusing to ambulate because of fear or pain. Collaborating with the client through assessment and education can aid in overcoming barriers. This client should not be delegated as this is not a routine situation. Forcing the client out of bed is not appropriate. The nurse should try all reasonable measure before acquiescing to the fact that the client will not ambulate

A nurse is assessing an older adult client with diabetes mellitus type 2. The client's latest hemoglobin A1C level is 8.5%. The client tells the nurse, "It's hard to eat healthy because I cannot drive to the grocery store." Which nursing action best addresses the client's situation? Educates the client on the importance of healthy eating to control their illness. Refers the client to a diabetes educator for information on disease management. Calls the client's family to arrange for transportation to the grocery store. Collaborates with case management for meal delivery services.

Collaborates with case management for meal delivery services. Rationale: The client's latest hemoglobin A1C level indicates poor management of the disease primarily due to an unhealthy diet as indicated by the client. The nurse identifies this as an opportunity to collaborate with case management for possible meal delivery services. Educating the client on healthy eating is important. However, this action does not address the issue of transportation. Referring the client to a diabetes educator does not address the problem of inaccessible groceries. Addressing the situation with the client's family does not guarantee reliable transportation.

A nurse is working with a graduate nurse. The graduate nurse provided information to a caller who identified themself as the client's spouse. After informing the client that their spouse had been given an update, the client stated, "What? I'm not married." What is the initial action by the nurse? Ask the client to provide a code for disclosure of health information Report the incident to the healthcare provider Review policies for handling confidential patient information Complete an incident report

Complete an incident report Rationale: The initial action of the nurse is to be accountable for the breach of confidentiality and complete an incident report as per protocol. Because of the breach of confidentiality, HIPAA protocol and policies for handling confidential patient information should be reviewed, but it is not an initial action of the nurse. In addition, an initial action of the nurse would not be to report the incident to the healthcare provider. For future protection of patient information, it is important that the client identifies those with who their health information may be shared. Many patients don't consent to give their family members updates on their condition. In addition, the use of a password or code may be incorporated to protect confidential client information.

The nurse is preparing to complete a daily assessment and dressing change for a client who is immobile and has a wound on the coccyx. Which of the following actions by the nurse is appropriate to manage time effectively? Remove the old dressing before gathering supplies Complete the dressing change while giving the client a bed bath Delegate the dressing change to the unlicensed assistive personnel Postpone the dressing change until after morning care has been completed

Complete the dressing change while giving the client a bed bath Rationale: The nurse should perform the wound assessment and dressing change while the client is being bathed. Combining these two actions is an efficient way to get both tasks completed because the client will need to be positioned and exposed for both procedures. The nurse cannot delegate an assessment to an unlicensed assistive personnel, and the other responses are not the most efficient use of the nurse's time.

A registered nurse who is functioning as the charge nurse is determining shift assignments. What is the best approach to determine which client assignments are appropriate for the licensed practical nurse (LPN)? Determine how many unlicensed assistive personnel (UAP) are available to help the LPN with client care Ask the LPN about prior experience caring for clients with various diagnoses Consider the LPN's scope of practice Refer to the list of technical tasks the LPN is trained to perform

Consider the LPN's scope of practice Rationale: LPN scope of practice is the best method to consider when assigning care. While the RN is responsible for ensuring a delegated assignment is completed appropriately and correctly, the LPN must be able to perform the skills or tasks independently and within their scope of practice.

The nurse is caring for a homeless client recently diagnosed with type 2 diabetes. Which actions demonstrate that the nurse is advocating for the patient? Select all that apply. Consult a social worker to help the client apply for Medicaid Arrange for a family member to provide housing for the client Provide a list of area pharmacies that offer free or reduced-price medications Arrange for a follow-up appointment at a free clinic Arrange for home delivery of prepared meals

Consult a social worker to help the client apply for Medicaid Provide a list of area pharmacies that offer free or reduced-price medications Arrange for a follow-up appointment at a free clinic Rationale: The nurse as an advocate needs to understand the client's current situation. It would not be possible for a homeless individual to receive scheduled meal delivery services. Family members should not be approached. The nurse could arrange appointments at a free clinic and refer the client to area pharmacies that provide free or reduced-price medications. The social worker should be consulted to help the client apply for Medicaid as well as for other available social services.

The nurse is caring for a homeless client recently diagnosed with type 2 diabetes. Which actions demonstrate that the nurse is advocating for the patient? Select all that apply. Consult a social worker to help the client apply for Medicaid. Arrange for a family member to provide housing for the client. Provide a list of area pharmacies that offer free or reduced-price medications. Arrange for a follow-up appointment at a free clinic. Arrange for home delivery of prepared meals.

Consult a social worker to help the client apply for Medicaid. Provide a list of area pharmacies that offer free or reduced-price medications. Arrange for a follow-up appointment at a free clinic. Rationale: The nurse as an advocate needs to understand the client's current situation. It would not be possible for a homeless individual to receive scheduled meal delivery services. Family members should not be approached. The nurse could arrange appointments at a free clinic and refer the client to area pharmacies that provide free or reduced-price medications. The social worker should be consulted to help the client apply for Medicaid, as well as for other available social services.

The nurse manager suspects a staff nurse may be suffering from substance use disorder (SUD). Which initial action by the nurse manager would be best? Meet with the nurse about the suspicions in a private meeting. Consult with human resources staff and follow their recommendations. Schedule a meeting with other staff members to collect information. Counsel the nurse about substance abuse and suggest treatment options.

Consult with human resources staff and follow their recommendations. Rationale: The best initial action is to consult with the human resources department to determine a plan of action regarding this situation. The nurse manager should follow the proper procedures for objectively documenting and reporting the nurse's behavior. The nurse manager could also consult the Employee Assistance Program (EAP) if one is available. Attempts should be made to help the nurse with SUD by providing resources for counseling and treatment for this disease, but those interventions would come later.

A nurse is providing care to a client with diverticulitis who is refusing all medical treatment. The client tells the nurse "I want to leave the hospital. I know how to manage my condition at home." Which action does the nurse perform next? Contact the healthcare provider, and explain the risks of leaving against medical advice Inform the charge nurse, and tell the client they cannot leave until medically stable Tell the client they are not ready to be discharged, and document refusal of treatment in the medical record Discontinue the client's intravenous access, and escort the client out of the facility

Contact the healthcare provider, and explain the risks of leaving against medical advice Rationale: An alert, competent client has the right to refuse treatment and leave the facility against medical advice. However, the nurse must first inform the healthcare provider and discuss the risks of leaving without completing medical treatment. The nurse cannot hold the client in the facility against their wishes. The determination of when a client is ready for discharge is not the sole decision of the nurse. The client must first be informed of the risks of leaving against medical advice prior to discontinuing intravenous access and escorting them out of the facility.

A nurse is providing education on insulin administration to a client with newly diagnosed diabetes. The client tells the nurse, "I don't want to take insulin for my diabetes. Please stop teaching me about injections." Which action does the nurse take next? Tell the client that refusing treatment will worsen their condition. Contact the healthcare team for alternative treatment options. Continue to instruct the client how to administer insulin. Document the client's refusal of treatment on the medical record.

Contact the healthcare team for alternative treatment options. Rationale: The client has the right to refuse treatment options. The nurse's role in advocacy is to provide alternative treatment options to a client in collaboration with the healthcare team. Emphasizing the client's refusal does not provide alternative options or promote advocacy. Continuing to instruct the client on insulin administration does not address the client's statement. Documenting the client's refusal of treatment is an important intervention. However, the client should be offered alternative treatment options first.

The nurse is caring for a client who is going to have an invasive procedure. The healthcare provider has completed the informed consent discussion. Based on knowledge of the nurse's role in informed consent, what action by the nurse is most appropriate? Answer any additional questions that the client has about the procedure Determine if the client has additional questions about the proposed procedure Sign the documentation in the role of the witness Encourage the family to support the client's decision

Determine if the client has additional questions about the proposed procedure Rationale: The most important part of the consent process is informing the client. A client's signature is meaningless if the client is not informed. Nurses are often told that when they obtain a client signature on a consent form, they are only witnessing the signature and not verifying that informed consent was obtained. However, nurses have ethical and professional accountabilities to ensure the client is fully informed and capable of giving consent. It is appropriate for the nurse to assess if the client has full understanding of the proposed treatment and then advocate to ensure that the client received the necessary information from the provider.

The nurse has been managing the care of a home health client for six weeks. In order to determine the quality of care being provided to the client by a home health aide, what should be the priority action by the nurse? Check the documentation of the home health aide for accuracy Investigate if the home health aide is prompt and stays an appropriate length of time Ask the client if they are satisfied with the care given by the home health aide Determine if the home health aide's care is consistent with the plan of care

Determine if the home health aide's care is consistent with the plan of care Rationale: Home health care allows clients to receive care in the home. Clients receive quality care from home health aides, who are supervised closely by registered nurses. The client's feedback is important, as it could impact their plan of care. The client's engagement in the plan of care is recommended. It is important that the nurse investigates accuracy of documentation, promptness, and length of stay by the home health aide. These are essential characteristics of a health care worker. These characteristics could also impact employment, as they are a component of professional behavior. Although the nurse must investigate all of these things, the first priority is an evaluation of the adherence to the plan of care. The plan of care is based on the reason for referral, the provider's orders, the initial nursing assessment, and the client's responses to the planned interventions. It is what justifies care of the client.

The nurse is caring for an adult client who experienced a closed head injury and is sedated and ventilated. The client does not have an advanced directive. Which action by the healthcare team is appropriate? Obtain consent from the emergency contact Ask the individual at the bedside to sign the consent form Determine the client's legal next of kin Continue to provide interventions based on presumed consent

Determine the client's legal next of kin Rationale: Informed consent is still required in an emergency circumstance if the client is cogent and conscious. In emergency situations were a decision-maker is unavailable and delay will harm the client, then informed consent is presumed for the client. The client is presumed to have consented to any and all relevant, emergency care such as intubation. However, once a client is stabilized, further treatments require consent from a legally acceptable decision-maker, including next of kin. The emergency contact may no participate in consent unless they are also legally designated to do so via advance directive or as next of kin.

The nurse manager has interviewed several nurses for a staff position. The most qualified nurse is one with a sensory impairment. In order to better understand the issue of reasonable accommodations, the nurse manager meets with the director of human resources. Which approach would be most appropriate? Consult with the facility attorney to determine any potential liability Recommend to the nurse to consider applying at another facility Inform the nurse with the disability that the position is not a good fit Determine the type of accommodations the nurse would require

Determine the type of accommodations the nurse would require Rationale: In the United States, the Americans with Disabilities Act (ADA) is designed to allow individuals with motor, cognitive, psychiatric, or sensory impairment equal access to employment opportunities. Employers must evaluate an applicant's ability to perform the job on a case-by-case basis and cannot discriminate on the basis of a disability. Employers are required to make "reasonable accommodations." An example of this would be installing a ramp for someone who uses a wheelchair. The other approaches are not appropriate and could be considered "discriminatory" and illegal.

The nurse is planning care for a client admitted from a nursing home with a diagnosis of pneumonia. The client is underweight and is developing a pressure injury on the sacrum. Which healthcare team member should be consulted to promote healing? Dietitian Occupational therapist Social worker Speech therapist

Dietitian Rationale: Factors that affect healing include age, circulation to and oxygenation of tissues, nutritional status, wound etiology, general health status and disease state, immunosuppression, medication use, and adherence to treatment plan. A registered dietitian (RD) manages and plans for the dietary needs of clients, based on knowledge about all aspects of nutrition. RDs can adapt specialized diets for the individual needs of clients and counsel and educate individual clients related to disease process. Speech therapists assess, diagnose, and treat communication disorders, such as aphasia and swallowing disorders, such as dysphagia. There is no indication that the client is experiencing a swallowing disorder.

The healthcare provider has called and asked the nurse to have the client sign the consent form to have a surgery scheduled for tomorrow. When approached, the client states, "I haven't spoken to my doctor yet." What action by the nurse is appropriate? Obtain the signature, and tell the client that the healthcare provider will be in to speak with them Do not obtain the signature, and inform the healthcare provider that they need to engage in the informed consent discussion Provide the client with the risks, benefits, and alternatives to the surgery, and obtain their signature on the informed consent document Document this as an informed consent refusal, and notify the healthcare provider

Do not obtain the signature, and inform the healthcare provider that they need to engage in the informed consent discussion Rationale: The cornerstone of the informed consent process is the discussion between the client and the healthcare provider. A client has the right to consent (or not) to any recommended procedure or treatment. The patient also has the right to enough information to give informed and meaningful consent. The client should be informed by the healthcare provider performing the procedure, not the nurse. In this case, the nurse should not obtain a signature and should inform the provider that they need to meet with the client. The client has not refused the procedure in this scenario.

A pre-op nurse is reviewing a surgical client's record and notes a do not resuscitate (DNR) advance directive. When asked to confirm, the client states, "I want everything done to me if my heart stops during surgery." Which action does the nurse take? Inform the client changes to the advance directive need to be performed legally Instruct the client to the inform the healthcare provider before the surgery begins Acknowledge the statement, and transfer the client to the operating room Document the client's statement, and inform the surgical team

Document the client's statement, and inform the surgical team Rationale: Do not resuscitate (DNR) advance directives can be suspended by the client at any time during their medical care. The nurse should clearly document the client's wishes and communicate the decision with the receiving healthcare team. DNR orders are honored when the client is unable to communicate their wishes. However, a mentally competent client can change their decision at any time. The client's statement should be documented by the staff member it was disclosed to. The nurse should acknowledge the statement but document the client's wishes in the medical record before transferring them to the operating room.

The nurse is admitting a new client to the emergency room who states that they have a large amount of cash in their wallet and valuable jewelry on them. Which action by the nurse is appropriate? Asking the client the total value of the items Telling the client that they need to keep all items in their pockets Placing the items in a belonging bag out of the client's view Documenting each of the client's items on a valuables inventory

Documenting each of the client's items on a valuables inventory Rationale: When a client has personal items, it is important to document what items they have with them and store them appropriately. In the event that a client states that they are missing an item, the nurse can look back on the valuables inventory to determine what items the client had upon admission. Items should either be in the client's view or safely stored after inventory. Asking the total value of the items is not appropriate.

The case management nurse is reviewing the medical record for an older adult client who was admitted with dehydration. The nurse notes the client has had several admissions over the past months for the same diagnosis. Which action should the case management nurse take to advocate cost effective care for this client? Suggest the client contact a family member to verify need for future admissions. Emphasize the importance of case management to coordinate outpatient follow-up care. Request that the health care provider discuss nursing home placement with the client. Listen compassionately to the client's concerns about recent hospitalizations.

Emphasize the importance of case management to coordinate outpatient follow-up care. Rationale: The nurse should ensure case management is actively involved in the client's care. Case management is essential to coordinating care for clients with chronic conditions such as social work, physical therapy, home health care, and other needs that may prevent further hospitalizations that can incur costs. The client's family member is not responsible to verify a need for future admission. This intervention would neither advocate for the client or be cost-effective. This client may be able to return to previous living arrangements with appropriate support, so a nursing home placement is inappropriate for this client. The nurse should always listen to a client's concerns with compassion, but this does not address cost-effective measures.

The nurse is reviewing client assignments at the beginning of the shift. Which task could be assigned to an unlicensed assistive person (UAP)? Clean and apply a dressing to a small pressure ulcer on the leg Empty a client's colostomy bag Stay with a client during the self-administration of insulin Monitor a client's response to passive range of motion exercise

Empty a client's colostomy bag Rationale: If the UAP has demonstrated competency in the task, s/he may empty a client's colostomy bag. This is an uncomplicated, routine task with an expected outcome. The other tasks involve one or more parts of the nursing process and cannot be assigned to an UAP.

The nurse in a long-term care facility is planning care for a client who has a colostomy in place. Which task is appropriate to delegate to the unlicensed assistive person (UAP)? Teach the client and family about proper colostomy care. Empty the colostomy bag contents and report the output amount. Measure the size, shape and color of the stoma. Change the colostomy wafer and bag apparatus.

Empty the colostomy bag contents and report the output amount. Rationale: Unlicensed assistive personnel or person (UAP) may assist with the care of a client with a colostomy. The UAP can perform simple tasks within their scope of training. The UAP can empty a colostomy bag and report the output amount to the nurse. This is a simple task that does not require assessment, teaching or action outside of their scope of practice (e.g., changing the colostomy wafer). Measuring the size, shape and color of the stoma is an assessment and should be done by the nurse. Teaching as well as changing the colostomy wafer and apparatus is outside the scope of the UAP and must be done by the nurse.

The nurse is developing the plan of care for a client with sickle cell anemia (SCA) who has a history of vaso-occlusive events. Which action by the nurse would be the most effective to include in the plan of care to prevent this occurrence? Emphasize the importance of immunizations Assist the client with relaxation techniques to relieve stress Encourage adequate fluid intake daily Advocate for daily administration of folic acid

Encourage adequate fluid intake daily Rationale: Adequate hydration is essential to prevent a vaso-occlusive crisis. Fluids should be increased during infection, with exposure to extreme heat or cold, or during excessive exercise to prevent sickling of cells leading to blood flow compromise and pain. Relaxation techniques, breathing exercises, and distraction are helpful for some patients to relieve stress, which may precipitate a vaso-occlusive event or the pain associated with one. To prevent infection, immunizations should be administered on schedule. Daily administration of folic acid may increase serum folate concentrations but has questionable use with sickle cell anemia.

The nurse is caring for a postoperative client following an abdominal hernia repair. Which intervention should the nurse implement to promote peristalsis? Administer the prescribed opioid analgesic Encourage the client to ambulate. Alternate solid with full liquid foods. Instruct the client to cough and deep breathe.

Encourage the client to ambulate. Rationale: Decreased intestinal peristalsis with the possible development of a postoperative ileus can occur as a result of drug therapy, anesthesia/analgesia, operative manipulation, and increased sympathetic nervous system excitation from stress after any surgery but is most common after open abdominal procedures. Nursing intervention to promote peristalsis include monitoring, ensuring adequate hydration, promotion of mobility/early ambulation, managing pain with nonopioid interventions, and when appropriate, pharmacologic management.

The client asks the nurse, "What is wrong with that person who is always screaming out?" What is an appropriate action by the nurse to address the client's concern? Ask if the client knows the other client before providing information. Tell the client about the condition in layperson's terms. Explain that information about other clients is considered private. Inform the client that the staff is handling the situation.

Explain that information about other clients is considered private. Rationale: The nurse should teach the client about HIPAA and confidentiality rules that govern any information concerning clients in a healthcare setting. Client information is private. The nurse should not tell the client about the condition or determine if the client knows the other client as this would be a breach in confidentiality and violation of privacy. It is a priority to address the client on confidentiality rules. Informing the client that the staff is handling the situation is dismissive and does not address the confidentiality issue.

A nurse is providing care to a client with a systemic infection who requires long-term intravenous antibiotics. The client states they are uncertain about an intravenous line and prefer oral antibiotics. Which action does the nurse perform next? Request a prescription for oral antibiotics from the healthcare provider. Explain to the patient why intravenous antibiotics are necessary. Inform the client that declining an intravenous line is refusal of treatment. Obtain a consult to social work for medication assistance.

Explain to the patient why intravenous antibiotics are necessary. Rationale: The nurse must provide information to the client about the treatment options. The client has the right to request alternative treatment after they have been thoroughly educated on the medical necessity of a treatment option. Requesting oral antibiotics from the healthcare provider does not advocate for the client's necessary medical care. The client has a right to refuse treatment. However, the nurse must first clarify any client concerns regarding primary treatment options. Obtaining a consult to social work for medication assistance is not indicated at this time. The client has not voiced difficulty with obtaining the medications.

The nurse manager considers changing staff assignments from 8-hour shifts to 12-hour shifts. A staff-selected planning committee has approved the change, yet staff are not receptive to the plan. Which action should the nurse manager take first? Explore how the planning committee evaluated barriers to the plan Design a different approach to deliver care with fewer staff Retain the previous staffing pattern for another six months Support the planning committee and post the new schedule

Explore how the planning committee evaluated barriers to the plan Rationale: A manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated. The manager wants to build the staff's skills at implementing change. Helping the committee evaluate its decision making is a useful step before rejecting or implementing the change. When possible, all affected by the change should be involved in the planning. The question is whether staff input has been thoroughly taken into consideration. This also illustrates the application of the nursing process to nonclient-care issues with assessment of the situation being the first step.

The nurse is teaching a client about a procedure to be done in the home. The client requires an interpreter. When using the interpreter, the nurse should take which of the following approaches? Face the client while presenting the information as the interpreter talks in the native language. Speak directly to the interpreter while presenting information, but allow the client time to ask questions. Talk to the interpreter in advance and leave the client and interpreter alone. Include a family member in the teaching session, and speak only to them.

Face the client while presenting the information as the interpreter talks in the native language. Rationale: Communication is the cornerstone of an effective teaching plan, especially when the nurse and client do not share the same culture. Interpreter services reduce liability, increase client satisfaction and improve client outcomes. Even if the nurse uses an interpreter, it is still critical that the nurse use personal spacing, eye contact, and touch that are acceptable to the client. Therefore, to face the client and present the information to them, allows the interpreter to translate the content. Facing the client also allows nonverbal communication to take place between the nurse and client. This could also be perceived as a sign of respect. It would be important to allow a family member to be present during the session, to help reinforce content with the client. However, the family member should not relay critical information to the client firsthand. Leaving the interpreter and client alone is not appropriate. The nurse needs to be present to field questions in real-time and ensure that the interpreter relays all pieces of information accurately.

There are perceived inequities about weekend scheduling on a nursing unit being discussed at a staff meeting. What action should the nurse manager take at this point? Help staff understand the complexity of scheduling issues Allow the staff to change assignments Facilitate a discussion about staffing alternatives Clarify reasons for current assignments

Facilitate a discussion about staffing alternatives Rationale: Part of the nurse manager's role is to be a change agent. By facilitating a discussion about scheduling alternatives, the staff becomes part of the solution, and it gives them an opportunity to voice varied perspectives. They become part of the decision-making process. This type of discussion will also help the staff understand the complexity of scheduling issues and the rationale for the current assignments. Allowing the staff to change assignments is a temporary solution and may not meet the needs of the unit.

The new nurse manager is preparing for a meeting with the staff to come up with ideas for how to reduce the number of falls on the unit. Which approach would be best for the nurse manager to use? Show a presentation on fall data Have the staff engage in brainstorming Conduct an anonymous staff survey Present a research article

Have the staff engage in brainstorming Rationale: Brainstorming combines a relaxed, informal approach to problem solving with lateral thinking. It encourages people to come up with thoughts and ideas. The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Therefore, having the staff engage in brainstorming during the meeting would be the best approach.

The nurse is discussing the importance of client confidentiality during a staff in-service. Which action by the staff would require the need for further teaching? The nurses complete end-of-shift reports at the bedside. Health information is written on the client's whiteboard. Computers are logged off when not in use. Staff requests to see identification before providing access to records.

Health information is written on the client's whiteboard. Rationale: The nurse should not put up the client's health information on a whiteboard to be seen by other healthcare workers. This would require further teaching of client confidentiality by the nurse. End-of-shift reports to the nurse coming on duty presented in the client's room or other secure area are a good way to protect client confidentiality instead of sharing information to those that do not need to know that information. Staff should log off from computerized workstations and monitor use of electronic health information to only those in direct care of the client.

The nurse is performing an assessment of one of their assigned clients. When would be the most appropriate time to document the assessment findings in the electronic medical record? Immediately after completing the assessment After completing assessments on all assigned clients At the conclusion of the nurse's shift While the assessment is in progress

Immediately after completing the assessment Rationale: The nurse should document assessment findings as soon as possible after completing the assessment to ensure accuracy. Delaying documentation until after other assessments have been performed or at the end of the shift increases the risk of inaccurate documentation. The nurse should avoid documentation in the middle of the assessment as this can cause the client to feed disconnected from the nurse.

The nurse is ambulating the client down the hall and notices the client with an unsteady gait when ambulating and needed a hand to hold so as not to fall. Which clinical documentation would be appropriate for the nurse to make? Immediately after getting the client safely back to bed, enters in the computer, "Client had unsteady gait when ambulating requiring 1 person assist to avoid falling." After ambulating the client, enters in the computer, "Client ambulated daily down the hall safely with 1-person assist." At the end of the shift the nurse enters into the computer, "Client ambulated down the hall requiring 1-person assist." Immediately after ambulating the client, enters in the computer, "Client reports feeling unsteady when ambulating with 1 person assist."

Immediately after getting the client safely back to bed, enters in the computer, "Client had unsteady gait when ambulating requiring 1 person assist to avoid falling." Rationale: When documenting care, the nurse should document at the time of care delivered, what was observed, the outcome, and evaluation. Documentation should occur immediately after care, including what the nurse assessed and which intervention was implemented. The documentation should be complete and not include assumptions.

The nurse is caring for a client with congestive heart failure who has anxiety about discharging home. To decrease readmission rates, the nurse recognizes that the client might benefit from which of the following services? Frequent home health visits Implementation of telehealth visits More written literature on discharge Follow up physical therapy evaluation

Implementation of telehealth visits Rationale: Using health information technology to improve quality, efficiency, and delivery of healthcare services is widely recommended. To assist with managing chronic conditions, the client should be offered telehealth visits. This would aide in decreasing anxiety and reduce the likelihood of the client returning to the emergency department for non-emergency issues. This will also facilitate the development of more personalized care plans. The frequency of the home health visits can be adjusted but may prove difficult due to client and nurse availability. Literature on discharge should still be given but will not likely decrease anxiety about the client's condition. Physical therapy evaluation should be considered prior to discharge.

The nurse is caring for a client who is two days post-surgery and notes that the client is experiencing a new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take? Educate the client's family on how to create a calm and safe environment for the client Inform the client's health care provider about the change in the client's condition Collaborate with the dietitian to identify ways to increase protein in the client's diet Encourage the client to schedule a follow-up appointment with their primary care provider

Inform the client's health care provider about the change in the client's condition Rationale: Delirium is considered a temporary, but acute condition, which is often characterized by sudden confusion, agitation and disorganized thinking. Factors that have been known to precipitate delirium include pain, dehydration, surgical procedures and opioid administration. Clients who are at highest risk for developing delirium are older hospitalized clients and clients who are admitted to intensive care units. All answer choices are plausible, but the best action for the nurse to take, would be to inform the health care provider of the client's change in condition. It is imperative that delirium is recognized early, as its causes are potentially reversible. Part of the client's plan of care would be to also instruct the client and family to schedule a follow-up visit with the primary care physician (PCP), develop a safe home environment and to maintain ample protein intake to facilitate wound healing.

The nurse is caring for a client at end of life whose advance directive states that they do not want food or fluids. The nurse notes a new order for a nasogastric tube with enteral feeding. What action by the nurse is appropriate? Insert the feeding tube Report the physician to the nurse manager Inform the healthcare provider of the instructions in the advance directive Ask a colleague to insert the tube

Inform the healthcare provider of the instructions in the advance directive Rationale: An advance directive is a legal document that goes into effect if the client is incapacitated and unable to participate in self-determination. One type of directive is a living will that spells out the client's wishes for certain medical treatments, such as resuscitation, ventilation, and tube feeding, etc. The nurse should collaborate with the provider who wrote the order as they may be unaware of the instructions in the advance directive. The nurse is not required to insert the tube and should not ask another colleague to do so. It may be appropriate to report the physician if an ethical dilemma arises, but at this time, this is not appropriate.

A day-shift nurse is performing rounds on several clients. Two of the clients tell the nurse that the night-shift nurse did not come into their room all night. The nurse reviews the clients' records and observes multiple progress notes by the night-shift nurse. Which action should the nurse take? Show the clients the progress notes written by the night-shift nurse Refer the clients' concerns to customer service Inform the nurse manager of the clients' statements Ask the rest of the clients if they have any concerns about their care

Inform the nurse manager of the clients' statements Rationale: The nurse should inform the nurse manager of the clients' statements. Multiple concerns regarding lack of nursing care should be referred to a supervisor for follow-up. Showing the clients the progress notes written by the night-shift nurse is not appropriate. The nurse may be falsifying documentation and require an investigation by a supervisor. Referring the client's concerns to customer service is not indicated unless the unit supervisor is aware of the situation. The nurse must follow the chain of command. Asking the rest of the clients if they have concerns about the care received is not the nurse's responsibility in an ethical dilemma.

The nurse is preparing to transport a client who is scheduled for a surgical procedure. The nurse observes that the informed consent for surgery has not been completed. Which action by the nurse is appropriate? Cancel the client's scheduled surgical procedure Tell the operating room that they will need to get consent Inform the surgeon that the client's consent form has not been signed Have the client sign before speaking with the surgeon

Inform the surgeon that the client's consent form has not been signed Rationale: The informed consent for a procedure must be obtained after the provider explains the purpose and the risks associated with the procedure. Clients cannot sign this consent without being informed first. Canceling the surgery and putting this task off for the operating room to complete is not appropriate.

The nurse is caring for an older adult client who has a history of falls related to impulsiveness and impaired gait. Which of the following strategies will best address this safety concern? Provide the client with the call bell. Place the client in a room near the nurse's station. Apply soft wrist restraints. Inform the team that the client's bed alarm should always be turned on.

Inform the team that the client's bed alarm should always be turned on. Rationale: The nurse must be vigilant for potential threats to the patient's safety, because impulsiveness may impair judgment. Close monitoring, frequent reorientation, hourly rounding, and implementing interventions to prevent falls (e.g., bed alarms) are essential. Just being closer to the nurse's station may not be enough. Informing all staff members of the client's risk and need for the bed alarm will aid in preventing a fall or injury. Soft wrist retraints are used to prevent injury from removal of a medical device and do not prevent falls. The client is impulsive so they may not use the call bell or if the call bell isn't answered quickly enough, the client may attempt to get out of bed alone.

A nurse reviews new prescriptions for several clients on a medical-surgical unit. Which intervention will the nurse perform first? Provide discharge instructions to a client post-abdominal surgery Initiate a patient-controlled analgesia pump for a client with uncontrolled pain Administer intravenous antibiotics to a newly admitted client Perform wound care on a client with a foot ulcer

Initiate a patient-controlled analgesia pump for a client with uncontrolled pain Rationale: The nurse should initiate the patient-controlled analgesia pump for a client with uncontrolled pain. Managing a client's pain (the fifth vital sign) is a priority intervention for the nurse. Discharge instructions indicate the client is stable. Providing discharge instructions to a stable client is not a priority intervention. Administering intravenous antibiotics to a newly admitted client is an important intervention but is not a priority for the nurse. The client with uncontrolled pain should be seen first. Wound care is a routine treatment and can be performed after the nurse completes the rest of the prescribed interventions.

A nurse is providing care to a newly admitted client with suspected meningitis. Which nursing care action will the nurse perform first? Administer prescribed antibiotics Initiate droplet precautions Place the client on seizure precautions Prep the client for a lumbar puncture

Initiate droplet precautions Rationale: The nurse should initiate droplet precautions before performing all other interventions. Meningitis is contagious and transmitted via oral secretions. The nurse should ensure infection control measures before performing nursing care. Administering prescribed antibiotics is an important intervention for the management of the condition; however, this action should be performed after isolation precautions are initiated. Meningitis can potentially cause an increase in intracranial pressure and produce seizure activity; however, placing the client on seizure precautions should be performed after infection control measures are in place. Prepping the client for a lumbar puncture assists in the diagnosis of the condition. This intervention is performed after the client is placed on droplet precautions.

A client arrives at the emergency department after a motor vehicle accident. The client is awake, responsive, and eupneic. Which action does the nurse perform next? Initiate peripheral intravenous access Perform a neurological assessment Remove all of the client's clothing Administer prescribed analgesics

Initiate peripheral intravenous access Question Explanation Rationale: The nurse should initiate peripheral intravenous access after establishing the client's airway and breathing patency. IV access allows for the administration of fluids and restoration of circulation. A neurological assessment should be performed during the disability portion of the ABCDE criteria after the nurse ensures effective circulation. Removing all of the client's clothing is performed during the exposure portion of the ABCDE criteria. This is the last step of the primary survey. The administration of prescribed analgesics is an important pain management intervention; however, this action is performed after the primary survey has been completed.

The nurse is reviewing the plan of care for a client with dehydration and has a serum calcium level of 7.2mg/dL. Which intervention is the priority for the nurse to implement? Monitor ECG for changes in P-waves. Obtain prescription to measure vitamin D level. Assess for Chvostek sign. Initiate seizure precautions.

Initiate seizure precautions. Rationale: The normal total serum calcium level is 8.6 to 10.2 mg/dL. Seizures may occur because hypocalcemia increases irritability of the central nervous system as well as the peripheral nervous system. A prolonged QT interval is seen on the ECG due to prolongation of the ST segment not a shortened P wave. Chvostek sign is contraction of the facial muscle that occurs with a light tap on the facial nerve. This is seen in hypocalcemia but does not present immediate danger to the client. Vitamin D levels should be evaluated but should be ordered by the HCP.

The nurse is identifying interventions for a plan of care developed for a client who had a stroke. The client has a nursing diagnosis of risk for falls. Which intervention would be appropriate to document for this client? Administration of prescribed pain medication Application of soft wrist restraints Initiation of a bed alarm Referral for physical therapy

Initiation of a bed alarm Rationale: The focus of interventions is based on the type of nursing diagnosis. For actual nursing diagnoses, such as acute pain, the nurse would implement interventions that address the problem and promote well-being. A risk nursing diagnosis, such as the risk for falls, the nurse would implement interventions to prevent the problem. Collaborative nursing diagnosis requires interventions that manage changes in status with nurse-prescribed and healthcare prescribed interventions, such as the use of restraints or referral for interdisciplinary care.

The nurse manager is reviewing ways that a nurse may risk disciplinary action related to licensure. Which action would put the nurse's license at risk? Inserting a central catheter under the direct supervision of a healthcare provider Participating in lateral violence and bullying on the unit Arriving to work with evidence of body odors Maintaining a habit of excessive absences and tardiness

Inserting a central catheter under the direct supervision of a healthcare provider Rationale: The nurse should recognize that inserting a peripheral intravenous central catheter (PICC) even under the direct supervision of a healthcare provider is outside the nurse's scope of practice, which is not allowed as per the state board of nursing and Nurse Practice Act. Participating in lateral violence/bullying on the unit, arriving to work with evidence of body odors, and maintaining a habit of excessive absences and tardiness do not pose a risk to disciplinary action regarding licensure but may result in loss of employment if agency policy is violated.

The nurse is developing the plan of care for a client with a history of coronary artery disease who was admitted with stable angina. Which intervention should the nurse implement? Limit the number of visitors. Initiate strict bedrest. Instruct client to eat small frequent meals. Encourage client to maintain cooler temperature in the room.

Instruct client to eat small frequent meals. Rationale: Clients with coronary artery disease have a decrease perfusion to the heart muscle, which can cause angina or chest pain. Stable angina occurs when the client experiences chest pain with activity but goes away with rest. The client should be instructed to eat small frequent meals to prevent increase blood flow to the digestive tract, which can increase angina. The client is permitted to ambulate, but only short distances and rest before chest pain begins. The client does not need to limit the number of visitors. Cooler temperatures can increase vasoconstriction, which can cause angina.

A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager implement first? Complete each task before beginning another activity Keep a time log of your day in hourly blocks for at least one week Set daily goals and establish priorities for each hour and every day Ask for additional assistance when you feel overwhelmed

Keep a time log of your day in hourly blocks for at least one week Rationale: Begin by applying the nursing process to the problem of time management. The initial step would be to assess current activities. This allows the nurse manager to establish a baseline of how his/her time is spent. This also aids in identifying where changes can be made.

The nurse is planning care for a client with respiratory failure who is receiving mechanical ventilation. The nurse should prioritize which equipment for the bedside? Pulse oximeter Suction canister Sterile suction catheters Manual resuscitation bag

Manual resuscitation bag Rationale: The client with pneumonia exhibiting respiratory compromise who is placed on intermittent mechanical ventilation depends on oxygen for tissue perfusion. The piece of equipment the nurse must prioritize is a manual resuscitation bag at the bedside in case of ventilator malfunction. Having a pulse oximeter at the bedside would be helpful to monitor oxygen saturation levels, but not a priority. The use of a functioning suction canister and sterile suction catheters may be necessary to clear the airway of secretions while the client is mechanically ventilated, but not a priority.

The registered nurse (RN) is working on a medical-surgical unit with a licensed practical nurse (LPN) and an unlicensed assistive person (UAP). Which of these activities is most appropriate for the RN to delegate to the UAP? Provide discharge instructions. Measure and record urine output. Perform a dressing change. Assess a client's orientation.

Measure and record urine output. Rationale: Basic and routine client care, such as measuring urine output, are activities typically within the level of training of a UAP and can therefore be delegated to the UAP. Only the RN can 'assess' and teach or provide discharge instructions.

A client requests not to be interrupted before 10 am because it interferes with their time to meditate. Which action should the nurse take first? Document the client's request in the medical record. Meet with the client to formulate a mutually agreeable schedule. Notify the dietary department about the client's request. Adjust administration times for prescribed medications.

Meet with the client to formulate a mutually agreeable schedule. Rationale: The nurse should communicate with the client to help determine how their meditation practice can be incorporated into the morning schedule. This is the first step in the nursing process and will help the nurse develop an individualized plan of care that incorporates respect for the client's personal choices and preferences.

The nurse is caring for a client who has a surgical wound infection. Which of the following strategies should be included in the client's plan of care? Utilize alcohol-based hand rubs before interacting with client Restrict visitors to the client. Monitor the client for signs of sepsis. Place the client on airborne transmission precautions.

Monitor the client for signs of sepsis. Rationale: The nurse should plan to monitor the client for signs of improvement or deterioration related to the infection. Early identification of sepsis improves client outcomes. Handwashing with soap and water is recommended for this client. The client may have visitors, but those visitors should be educated on infection control practices. There is no indication for airborne transmission precautions for this client.

The nurse manager has implemented a team care process that pairs each new graduate nurse with an experienced unlicensed assistive personnel (UAP) to address increased client acuity levels. Which is the best action to evaluate the outcome of the quality improvement initiative? Assign the charge nurse to monitor the graduate nurse. Monitor the unit-based patient satisfaction scores. Require daily reports from the graduate nurse on the UAP performance. Provide an in-service on the benefits of team nursing.

Monitor the unit-based patient satisfaction scores. Rationale: To determine if the management initiative (i.e., pairing new graduate nurse and experienced unlicensed assistive personnel) results in the desired outcome of improved care, the best action is to monitor the unit-based patient satisfaction scores. The charge nurse would not have time to complete his or her own work in addition to their role as a charge nurse. Requiring daily reports from the graduate nurse on the UAP performance would not be an effective use of time and may not be an objective evaluation of the UAP's performance. Providing an in-service on the benefits of team nursing would provide needed education for the change in the proposed model of nursing but would not be the best action to evaluate an improvement in care.

A nurse is working on a hospital medical-surgical unit. Which tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. Insertion of an indwelling urinary catheter Educating a client about dietary modifications Monitoring and documentation of client intake and output Application of barrier cream to the perineal area Assisting a client with ambulation two days post-operatively

Monitoring and documentation of client intake and output Application of barrier cream to the perineal area Assisting a client with ambulation two days post-operatively Rationale: The nurse can delegate tasks to unlicensed assistive personnel (UAP) when it follows within the UAP's scope of practice. Application of barrier cream to the perineal area, assisting a client with ambulation, and monitoring and documentation of client intake and output are all within the UAP's scope of practice and can appropriately be delegated by the nurse. UAPs are unable to insert an indwelling urinary catheter, as this is considered an invasive procedure that should be done by the nurse. Additionally, UAP are not able to provide patient education or teaching.

A nurse is working on a hospital medical-surgical unit. Which tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. Insertion of an indwelling urinary catheter Educating a client about dietary modifications Monitoring and documentation of client intake and output Application of barrier cream to the perineal area Assisting a client with ambulation two days postoperatively

Monitoring and documentation of client intake and output Application of barrier cream to the perineal area Assisting a client with ambulation two days postoperatively Rationale: The nurse can delegate tasks to unlicensed assistive personnel (UAP) when it follows within the UAP's scope of practice. Application of barrier cream to the perineal area, assisting a client with ambulation, and monitoring and documentation of client intake and output are all within the UAP's scope of practice and can appropriately be delegated by the nurse. UAPs are unable to insert an indwelling urinary catheter as this is considered an invasive procedure that should be done by the nurse. Additionally, UAP are not able to provide patient education or teaching.

The nurse is preparing a questionnaire for the pediatric inpatient unit to evaluate patient satisfaction. The nurse understands which of the following could impact the results? Socioeconomic status Marital status of the parent Moral evaluations Family size

Moral evaluations Rationale: For the nurse to properly evaluate patient satisfaction, moral evolutions should be reviewed and understood. Moral evaluations are judgments that conform to the standard of what is right and good. Moral evaluations assess human actions and institutions and avoid giving special place to a person's own welfare. Socioeconomic status, family size, and marital status are not likely to influence the results but should all be taken into consideration when caring for clients.

A pediatric client is seen by the school nurse who notices several deep, round wounds with well-defined edges that resemble cigarette burns. The client reveals that a caregiver has been abusive. What is the nurse's first responsibility in caring for this child? Inform the other caretaker of the injuries Notify law enforcement Notify Child Protective Services Document all the areas of injury

Notify Child Protective Services Rationale: Nurses are mandated reporters of abuse and, as such, are required to notify the state's child protective services department. It is not mandated that the reporter notify the caregivers that a report has been filed. It is also not necessary to notify the police unless the client is in immediate danger. Child protective services will involve law enforcement as needed. All areas of injury should be documented, but the child's safety is the priority intervention.

The nurse is assessing an older adult client who lives with an adult child. The client has bruising in various stages on the back and upper arms and reports "not knowing how those got there." Which of the following actions is appropriate? Notify the charge nurse Ask for assistance from hospital security personnel Call the abuse hotline Inform the social worker

Notify the charge nurse Rationale: Indications of elder abuse are often misinterpreted as normal signs of aging. Careful observation of the relationship between the older adult and the caregiver may be the first evidence that the older adult is a victim of abuse. Older adults who have been physically abused may have injuries that are incompatible with the client or caregiver's version of how the injury occurred. Evidence of previously untreated injuries or suspicious cuts and bruises should alert healthcare providers to the possibility of physical abuse. The bedside nurse should report abuse via the chain of command, which would include the charge nurse or nurse manager.

A nurse is providing care to a client who is on a ventilator following a stroke. The client's spouse is denying consent to several prescribed medical interventions. Which action does the nurse perform next? Follow the wishes of the client's spouse Perform the medical interventions as prescribed Notify the client's primary healthcare team Document refusal of care in the client's medical record

Notify the client's primary healthcare team Rationale: The nurse advocate must act in the best interest of the client and notify the primary healthcare team. The spouse's lack of consent to medical interventions may harm the client and the reasons for refusal should be assessed. The nurse must continue to be the client's advocate despite the inability to communicate with the client. Performing the medical interventions will cause mistrust in the client's spouse. Documenting the refusal of care is an important intervention. However, the nurse must first advocate for the client's medical care

While being admitted for surgery, a client refuses to sign the surgical consent form. Which nursing actions should the nurse take? Select all that apply. Notify the health care provider. Have a family member sign the consent form. Convince the client to sign the consent form. Document the client's refusal in the medical record. Inform the unit charge nurse

Notify the health care provider. Document the client's refusal in the medical record. Inform the unit charge nurse Rationale: The nurse should document the client's refusal to sign the consent form in the medical record. The nurse is responsible for notifying the charge nurse to keep them informed of the client's decision. The health care provider should be notified so they can discuss the consequences of not having the surgery and potential treatment alternatives with the client. It is not in the nurse's scope to convince a client to have a procedure they have the right to refuse. Unless the client has been deemed incompetent, the nurse should not have anyone sign on their behalf when they have refused treatment because this could create a claim of battery.

The charge nurse in the emergency department receives a radio call from Emergency Medical Services (EMS) stating that there has been a large structure fire with multiple victims. Which action should the charge nurse take first, before the victims start to arrive? Call for a medical evacuation helicopter to be on standby. Prepare the trauma room and lay out supplies. Activate the disaster plan Notify the nursing supervisor and request additional staff.

Notify the nursing supervisor and request additional staff. Rationale: The ED charge nurse needs to assess, supervise and coordinate staff to maintain full readiness of the ED. The first priority for the ED charge nurse to notify the nursing supervisor that additional nursing staff will be needed. Preparing the trauma room will be next. It is unknown if a medical evacuation helicopter is needed at this point and more data would need to be collected about the victims to make this determination. A hazardous materials decontamination plan is used for mass casualty incidents that involve exposure to toxic chemicals.

A client is being prepped for a surgical procedure and the nurse is reviewing the consent form with the client. The client asks, "Is there any other way to take care of this without having surgery?" What should the nurse do next? Tell the client if they don't want the surgery, they don't have to have it. Reassure the client that the surgery is the best treatment option. Notify the operating room and cancel the surgery. Notify the surgeon that the client has additional questions about the surgery.

Notify the surgeon that the client has additional questions about the surgery. Rationale: The client should only sign the consent form after all their questions are answered. Notify the appropriate health care provider if the client needs additional information about the surgery. Once the client has all the necessary information, they can then decide not to sign the informed consent form and the surgery can be cancelled. Offering false reassurance violates the client's right to autonomy. Cancelling the surgery is premature at this time.

The nurse is caring for a client diagnosed with osteosarcoma who has been experiencing severe pain. The client received oxycodone 5 mg one hour ago and now reports that the pain is 8/10. Which action by the nurse best demonstrates the role of client advocate? Calling the family to come sit with the client Notifying the healthcare provider that the treatment is ineffective Suggesting guided imagery as an adjunct treatment approach Asking the client if they have tried complementary therapies

Notifying the healthcare provider that the treatment is ineffective Rationale: Most patients with metastatic bone disease experience moderate to severe bone pain. Oxycodone 5 mg is an immediate release opioid agonist which is administered every 6 hours PRN. The nurse assesses for decreased pain (patient reports) and a general feeling of well-being. Untreated pain has physiological and psychosocial consequences. The nurse will best advocate for more effective pain management by notifying the provider that the opioid medication has been ineffective. While multimodal approaches may combine pharmacologic and non-pharmacologic therapies, the first intervention is to notify the provider who will likely increase the dosage or change the type of opiate being administered. Advocating for the client requires knowledge of best practices for pain management.

The new graduate nurse interviews for a nursing position on a hospital unit that uses a shared governance model. Which description best illustrates this concept? The hospital's executive team determines the standards of nursing care. The manager of the nursing unit develops and implements changes on the unit. Nurses and physicians collaborate to discuss client care standards. Nurses work together to implement changes and share responsibility for client outcomes.

Nurses work together to implement changes and share responsibility for client outcomes. Rationale: Shared governance or self-governance is a method of organizational design. It promotes the empowerment of nurses and gives them responsibility for client care issues and outcomes. Chaired by senior clinical nursing staff, these groups are empowered to establish and maintain standards of nursing care and practice on their unit. The committees review and establish standards of care, develop policy and procedures, resolve client satisfaction issue, and/or develop new documentation tools. It is important to focus on client outcomes to ensure high-quality care is delivered on the nursing unit.

A client arrives at urgent care after sustaining a fall. During the physical assessment, the nurse notes decreased passive range of motion to the left hip and the client verbalizes a 3/10 pain with movement. Which action does the nurse expect to perform next? Obtain a prescription for an X-ray, and refer the client to radiology Educate the client on mobility, and demonstrate range of motion exercises Assess the client's gait, and document the findings Complete the physical assessment, and prepare the client for discharge

Obtain a prescription for an X-ray, and refer the client to radiology Rationale: The client's symptoms are indicative of injury to the left hip. The nurse should expect to obtain a prescription for radiologic studies and refer the client to the appropriate department. Educating the client on the importance of mobility is important. However, injury to the extremity must be ruled out first. The client verbalizes pain with passive range of motion. Assessing the client's gait may cause further injury to the extremity. The client cannot be safely discharged until the abnormal findings are addressed.

A nurse is providing care to an older adult client with hypertension who is on a low sodium diet. The client states the food tastes bland and refuses to eat the meals provided. Which action does the nurse perform? Educate the client on the importance of a low sodium diet. Allow the client to select their food preferences. Obtain a registered dietitian consult. Encourage the client's family to bring food from home.

Obtain a registered dietitian consult. Rationale: The client's refusal to eat the prescribed diet will lead to inadequate nutrient intake. The nurse should obtain a consult to a dietitian for further assessment and suggested alternatives. Educating the client on their diet is important; however, this does not address the reason for the client's refusal to eat. Allowing the client to select their food preferences does not fulfill the ordered prescription. Encouraging family to bring the client food from home is not appropriate. The nurse is unable to verify the prepared food is low in sodium.

A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which of the following interview strategies would be the best approach by the nurse manager? Obtain an interview guide from human resources Ask personal information of applicants Use simple questions requiring a "yes" or "no" answer Vary the interview style for each candidate

Obtain an interview guide from human resources Rationale: The nurse manager is an active part of the interview process. As a result, they need to know what interview questions to ask a potential employee. The manager should not ask yes or no questions. Instead, they should ask about the candidate's experience, why they would be valuable to the company and what they would do in certain situations. The new manager should obtain an interview guide from human resources (HR) for consistency in reviewing each applicant. An interview guide used for each candidate enables the nurse manager to be more objective in decision-making. The nurse manager should use resources available in the agency before the manager attempts to develop one from scratch. Although it's nice to give a variety of questions, standardized questions and style should be used to compare applicant responses and behaviors. The manager should not ask personal information of applicants to ensure they can meet job demands. Asking certain personal questions is prohibited.

A health care provider asks the nurse to assist with obtaining consent for central line placement in a client who is deaf. While the health care provider explains the procedure and risks to the client and family member, the client and family member text each other using their cell phones. What is the most appropriate nursing action? Stand next to the client and verify that the information in the texts is accurate Obtain interpreter services for the client Request the health care provider allow extra time to explain information Remind the health care provider to ask one question at a time

Obtain interpreter services for the client Rationale: Communication is critical in health care settings. Under the Americans with Disabilities Act (ADA), hospitals must provide effective means of communication for patients who are deaf or hard of hearing. When obtaining informed consent from a client, it is important for the provider to speak slowly and ask one question at a time. However, interpreter services are needed for clients who are deaf. The client must understand the procedure and risks associated with the procedure in order to give informed consent. Interpreter services for clients who are deaf can be provided through video remote interpreting, closed captioning, and texting. The client's family should not be relied on to interpret medical information. Family members may be unable to accurately interpret in the emotional situation that often exists during a client's hospitalization.

A health care provider asks the nurse to assist with obtaining consent for central line placement, in a client who is deaf. While the health care provider explains the procedure and risks to the client and family member, the client and family member text each other using their cell phones. What is the most appropriate nursing action? Stand next to the client and verify that the information in the texts is accurate Obtain interpreter services for the client. Request the health care provider allow extra time to explain information Remind the health care provider to ask one question at a time

Obtain interpreter services for the client. Rationale: Communication is critical in health care settings. Under the Americans with Disabilities Act (ADA), hospitals must provide effective means of communication for patients who are deaf or hard of hearing. When obtaining informed consent from a client, it is important for the provider to speak slowly and ask one question at a time. However, interpreter services are needed for clients who are deaf. The client must understand the procedure and risks associated with the procedure in order to give informed consent. Interpreter services for clients who are deaf can be provided through video remote interpreting, closed captioning and texting. The client's family should not be relied on to interpret medical information. Family members may be unable to accurately interpret in the emotional situation that often exists during a client's hospitalization.

An inpatient client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." Which action should the nurse take? Calmly focus on reality orientation to time, place and person. Assist with the report of the client's complaint to the police. Obtain more details of the client's claim of abuse by a nurse. Document the statement on the client's chart and report it to the nursing manager.

Obtain more details of the client's claim of abuse by a nurse. Rationale: The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, assessment before interventions and before documenting or reporting the complaint.

The nurse is planning care for a client with heart failure. Which of the following tasks is appropriate to delegate to experienced unlicensed assistive personnel (UAP)? Monitor the client for shortness of breath after ambulation. Instruct the client to alternate activity with rest. Obtain the blood pressure and pulse rate after ambulation. Determine whether the client is ready to increase the activity level.

Obtain the blood pressure and pulse rate after ambulation. Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. UAPs are not licensed; therefore, they cannot teach or assess a client. Therefore, any instruction or assessment must be done by the registered nurse. UAPs can collect data but only the nurse can interpret this data.

The nurse is admitting a client with cellulitis who uses a wheelchair for mobility. The nurse notes a prescription for IV antibiotics. Which action should the nurse take to promote safe admission? Check the client's renal function Obtain the client's weight Review previous hospitalizations Initiate a bed alarm

Obtain the client's weight Rationale: Clients with disabilities should expect the same clinical assessment with those without disability. It is the responsibility of the nurse to ensure the client's weight is accurately documented on admission as this could affect the medication dosing. The renal function can be reviewed by the pharmacy and healthcare provider and adjustments can be made prior to dosing. Previous hospitalizations are important to update in the history but will not have any direct correlation to the client's current condition. A bed alarm is initiated if the client is at risk for falls, and the nurse would need to complete a falls assessment to identify appropriate interventions.

A nurse is working with an unlicensed assistive personal (UAP) to care for a client who is three days postoperative an abdominal hysterectomy. The UAP reports to the nurse the client's dressing is saturated with sanguineous drainage. Which task should the nurse delegate to the UAP? Reinforce the dressing. Check to see if the client needs to void. Verify that the incision is intact. Obtain vital signs.

Obtain vital signs. Rationale: When caring for a client who is postoperative abdominal hysterectomy and is exhibiting signs of bleeding, the nurse should delegate the UAP the task of obtaining vital signs. Checking to see if the client has to void, which bladder distention can increase pressure on the surgical incision, should be done by the nurse. Assessing the incision and reinforcing the dressing should be done by the nurse.

The nurse is caring for a client with acute kidney injury. Which of the following actions can the nurse delegate to the unlicensed assistive personnel (UAP)? Check for the presence of edema. Listen for bowel sounds. Obtain vital signs. Monitor fluid balance.

Obtain vital signs. Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. UAPs are not licensed and therefore cannot assess a client. Therefore, any instruction or assessment must be done by the registered nurse. UAPs can collect data but only the nurse can interpret this data.

The nurse is caring for a group of hospitalized clients. Which task is appropriate to delegate to the unlicensed assistive personnel? Assessing the severity of peripheral edema in a client Obtaining vital signs on a client who had surgery yesterday Measuring the leg circumference of a client with calf pain Reporting back on the appearance of a pressure injury

Obtaining vital signs on a client who had surgery yesterday Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they may not delegate the nursing process itself. Nursing care or tasks that should never be delegated except to another RN include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated should be based on the training and competence of the individual accepting the delegation. The UAP can obtain vital signs on a stable client. The client with calf pain may be experiencing a DVT, so this task should not be delegated. UAPs cannot assess or evaluate, so the pressure injury should be observed by the registered nurse.

A nurse receives a discharge prescription for a client with right hemiplegia. The client tells the nurse, "I do not want to go home and burden my family." Which action does the nurse take next? Contacts the healthcare provider to cancel the discharge. Calls the client's family to notify them of the client's statement. Obtains a referral for a social work consult. Continues to prepare the client's discharge.

Obtains a referral for a social work consult. Rationale: The nurse's role as an advocate is to respect the client's wishes and offer all alternative treatment options. A social work consult will help assess other discharge options for the client. Canceling the discharge is not an appropriate intervention if the client is stable. Disclosing the statement to the family violates the client's privacy and may cause the nurse to lose rapport with the client. Continuing to prepare the discharge does not address the client's concern.

The nurse is caring for a client who has a history of cerebrovascular accident. The client is awake and alert but struggles to feed themself due to fine motor dysfunction. Which of the following members of the healthcare team would best meet the client's need? Physical therapist Occupational therapist Healthcare provider Case manager

Occupational therapist Rationale: The occupational therapist (OT) can evaluate the functional level of the client and teach activities to promote self-care in activities of daily living, such as feeding oneself. The OT can also provide assistance with securing any needed assistive equipment. The physical therapist plays a role in assisting the client to develop strength and gross motor function. The healthcare provider and case manager are not best suited for this client's need in the inpatient setting.

The home health nurse is caring for client diagnosed with diabetes mellitus and arthritis. The client is having difficulties drawing up insulin. Which of the following resources would be most appropriate for the nurse to refer the client to? Activity therapist from the community center Social worker from the local hospital Occupational therapist from the home health agency Another client diagnosed with diabetes mellitus

Occupational therapist from the home health agency Rationale: In order for the client to administer their insulin, they would need to fill the correct syringe with the right amount of insulin, decide where to give the injection, and know how to give the injection. Another client with diabetes would not be appropriate. It would be considered a violation of Health Insurance Portability and Accountability Act (HIPAA). In addition, the other client is not a health care worker. A social worker would help the client identify community resources that are needed for their health care (i.e. support services, transportation, meal services, etc.). An activity therapist would plan and coordinate recreation programs for patients in hospitals or long-term care facilities. Activities include trips, social activities, and arts and crafts. An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection. The other resources would not be helpful in this situation.

The home health nurse is caring for the client diagnosed with diabetes mellitus and arthritis. The client is having difficulties drawing up insulin. Which of the following resources would be most appropriate for the nurse to refer the client to? Activity therapist from the community center Social worker from the local hospital Occupational therapist from the home health agency Another client diagnosed with diabetes mellitus

Occupational therapist from the home health agency Rationale: In order for the client to administer their insulin, they would need to fill the correct syringe with the right amount of insulin, decide where to give the injection, and know how to give the injection. Another client with diabetes would not be appropriate. It would be considered a violation of the Health Insurance Portability and Accountability Act (HIPAA). In addition, the other client is not a health care worker. A social worker would help the client identify community resources that are needed for their health care (i.e. support services, transportation, meal services, etc.). An activity therapist would plan and coordinate recreation programs for patients in hospitals or long-term care facilities. Activities include trips, social activities, and arts and crafts. An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection. The other resources would not be helpful in this situation.

The nurse is caring for a group of clients on a medical unit. A new graduate nurse is hanging a bag of heparin for continuous infusion for one of their assigned clients. How can the nurse be a resource for the new graduate nurse? Offer to double check the hourly rate when the new nurse is programming the pump Inform the nurse that the medication cannot be infused on this unit Tell the nurse that the bag of medication should be reviewed with another nurse before being hung Visit the client's room after the medication is hung to ensure the infusion rate is correct

Offer to double check the hourly rate when the new nurse is programming the pump Rationale: The Joint Commission on Accreditation of Healthcare Organizations (TJC) has issued a bulletin listing "high-alert" medications that have the highest risk of causing injury when misused. The list includes intravenous anticoagulants (heparin). TJC recommends strategies such as a system that confirms the correct drug, dosage, patient, time, and route. Nurses should ask a colleague to double-check measurements of heparin prior to administration. A more seasoned nurse should offer to double-check medications prior to administration to protect client safety. Checking doses after infusions have started does not reduce the risk of injury.

The nurse is working to improve patient satisfaction on the preoperative unit after having poor scores over the last quarter. A new bedside tool was implemented six months ago, and the results have been compiled for review. The nurse recognizes the processes as which acronym? SBAR PDSA EBP STEPPS

PDSA Rationale: The PDSA model stands for plan, do, study, act. This is a cycle used for testing change in the work setting by following the steps strategically. The project should be implemented on a small scale to observe the change effect. SBAR is used for communication. EBP is the acronym for evidenced-based practice. STEPPS is a framework with five key principles and is based on a team structure.

The nurse is caring for client in acute respiratory distress who had an atrial blood gas level collected. . When reviewing the results, the nurse should understand that PAO2 indicates which finding? Partial pressure of alveolar oxygen Partial pressure of arterial oxygen Partial pressure of carbon dioxide Partial pressure of arterial carbon dioxide

Partial pressure of arterial oxygen Rationale: Arterial blood gas is a common diagnostic modality ordered for clients in respiratory distress. The abbreviation of PO2 refers to partial alveolar oxygen pressure.

The nurse is caring for a client who is preparing to have a cholecystectomy and has a history of type II diabetes. Which action is appropriate to delegate to an unlicensed assistive personnel (UAP)? Perform a fingerstick blood glucose test and report the findings to the registered nurse. Discuss the reason for the use of insulin therapy during the immediate postoperative period with the client. Administer the prescribed lispro insulin before transporting the client to surgery. Plan strategies to minimize the risk for abnormal blood sugar results during the postoperative period.

Perform a fingerstick blood glucose test and report the findings to the registered nurse. Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. UAPs are not licensed; therefore, they cannot engage in the nursing process nor practice inside the nursing scope of practice. Therefore, any assessment, planning, instruction, or medication administration must be done by the registered nurse. UAPs can collect data but only the nurse can interpret this data.

An unresponsive client arrives at the emergency department after sustaining a fall from a ladder. Which action will the nurse perform first? Auscultate the client's bilateral breath sounds Initiate peripheral intravenous access Perform a modified jaw thrust maneuver Administer prescribed pain medication

Perform a modified jaw thrust maneuver Rationale: The nurse's priority is to establish the client's airway. A client who is unresponsive after trauma may have cervical spine injuries. The nurse performs a modified jaw thrust maneuver to safely open the client's airway. Auscultation of the client's breath sounds should be performed after the nurse verifies the client's airway is secured. Initiating peripheral intravenous access restores circulation, which should be assessed after airway and breathing. The administration of pain medication should be performed after the nurse completes the primary survey.

A client has a nasogastric tube after colon surgery. Which of these tasks is appropriate for the nurse to assign to an unlicensed assistive person (UAP)? Monitor the type and amount of nasogastric tube drainage. Perform nostril and mouth care every two hours or as ordered. Monitor the client for nausea or other gastric complications. Irrigate the nasogastric tube with the ordered solution

Perform nostril and mouth care every two hours or as ordered. Rationale: When delegating the nurse needs to consider the scope of practice of the UAP. The UAP can perform tasks that are routine with expected outcomes, such as personal hygiene. Thus, performing nostril and mouth care is an appropriate task for the UAP. Irrigating the nasogastric tube, monitoring the client for complications and monitoring drainage all may have unexpected outcomes, and are part of the role of the nurse and should not be assigned to the UAP.

The nurse is caring for a client that has been transferred from critical care following abdominal surgery. Which nursing interventions would be safely delegated to a licensed practical nurse (LPN) to assist the nurse? Perform wound care after the initial assessment. Administer prescribed unit of blood. Assess bowel sounds and advance diet as prescribed. Teach the client how to splint the incision to decrease pain.

Perform wound care after the initial assessment. Rationale: A complete and thorough assessment is needed by the registered nurse as the client was just transferred from the critical care unit. The nurse may delegate to the LPN responsibilities of wound care after the initial assessment. The nurse would administer prescribed unit of blood as this is out of scope of practice for the LPN. The nurse would also complete any initial postoperative assessment such as bowel sounds and teaching because the nurse holds the responsibility for this task within legal scope of practice.

The nurse is evaluating the time management skills of staff members. Which finding indicates an appropriate use of time while completing a client's morning hygiene? Performing a bed linen change while completing a bed bath Postponing feeding assistance until after morning care has been completed Making several trips to the supply room to gather supplies Having personal conversation with other staff before entering each client room

Performing a bed linen change while completing a bed bath Rationale: Clustering tasks that can be completed simultaneously is a good time management technique. In this case, completing both a bed bath and a linen change at the same time is an efficient use of time. Postponing feeding assistance until after morning care is not an efficient use of time because the client may require additional assistance with hygiene care following eating.

The experienced nurse is precepting a graduate nurse who reports having difficulty completing tasks on time. Which action by the graduate nurse would require follow-up by the experienced nurse? Asks for help with dosage calculation Requires two attempts to start a peripheral IV site Performs all tasks without delegation to nursing personnel Struggles with making staffing assignments

Performs all tasks without delegation to nursing personnel Rationale: Over-delegating is a frequent cause of ineffective time management seen in the new nurse. The nurse would need to intervene and review the scope of practice, prioritization, and delegation of care with the graduate nurse. When in doubt, the nurse should always ask for assistance with dosage calculations. Intravenous (IV) insertion is a skill that develops with experience and time. New graduates are not in charge of running the unit or making staffing assignments.

The nurse is caring for a client diagnosed with a left hemisphere cerebrovascular accident. The client has a new prescription for ambulation. Which team member should the nurse collaborate with to promote an optimal outcome? Physical therapist Case manager Occupational therapist Unlicensed assistive personnel

Physical therapist Rationale: The nurse should collaborate with the physical therapist, who can assess the client and determine the amount of assistance required to safely ambulate the client. The case manager coordinates the care of a caseload of patients through facilitating communication between nurses, other healthcare personnel who provide care, and insurance companies. That is not the appropriate team member for this particular need. The occupational therapist can assist this client to complete activities of daily living (ADLs) but not ambulation. The unlicensed assistive personnel may be needed to assist with ambulation, but this is not the first person the nurse would collaborate with.

The nurse is caring for a client in respiratory distress who has been receiving 100% oxygen via nonrebreather mask and now appears fatigued. The client's most recent arterial blood gas is pH 7.29 pCO2 55, pO2 59, HCO3 18. The nurse will plan to do which of the following interventions first? Obtain a serum lactate level. Reassure the client. Prepare for imminent intubation. Request a prescription for IV sodium bicarbonate.

Prepare for imminent intubation. Rationale: Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. Endotracheal intubation and mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the underlying cause is corrected. This is the priority in order to prevent deterioration to respiratory arrest and possibly death. All other interventions may be appropriate, but not the priority.

A nurse is precepting a graduate nurse providing care to a client with a sacral pressure ulcer. During wound care, the graduate nurse takes photos of the client's wound with a personal cell phone. Which action should the nurse take next? Prompt the graduate nurse to review the code of ethics Report the graduate nurse to the nursing supervisor Ask the graduate nurse to obtain the client's consent Ensure the graduate nurse does not include identifying information in the photo

Prompt the graduate nurse to review the code of ethics Rationale: Protection of a client's right to privacy and confidentiality is part of provision 3 of the nursing code of ethics. The graduate nurse should be prompted to review this provision to understand the client's right to privacy and confidentiality. As a preceptor, the nurse should guide the graduate nurse to review the code of ethics before reporting the behavior to a nursing supervisor. Asking the graduate nurse to obtain the client's consent does not explain to the graduate nurse why this action is necessary for the protection of client privacy and confidentiality. Taking a photo without the client's consent is a breach of privacy and goes against provision 3 of the nursing code of ethics.

The nurse is educating a client receiving a prescription for an oral chemotherapeutic using the assistance of a certified translator. The client's primary spoken language is Portuguese. What methods will the nurse include in the teaching plan? Observe the client complete a return demonstration Provide the client with written instructions in Portuguese Have the client complete a post-test on the content taught Request that a visiting nurse provide additional teaching

Provide the client with written instructions in Portuguese Rationale: The client should be provided with written materials in the primary language. Written materials supplement the instruction provided by the nurse and translator. Return demonstration is appropriate for a client being taught a technical skill and not self-administration of a "pill". A post-test would not be appropriate unless available in the client's spoken language and at the client's reading level. It is not cost effective for a visiting nurse to see this client for additional education on this matter unless they are visiting for other conditions.

The registered nurse is working with a licensed practical nurse (LPN/VN) in a team nursing model. Which elements of the nursing process can be delegated to the licensed practical nurse? Assessment of the client Development of the plan of care Provision of nursing interventions Evaluation if goals are met

Provision of nursing interventions Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated should be based on the training and competence of the individual accepting the delegation.

The nurse is interested in improving falls on the orthopedic unit. The nurse understands that which action needs to be taken first? Put together a team. Gather data on falls. Research evidence-based practice. Create a questionnaire.

Put together a team. Rationale: The model for improvement known as rapid cycle testing can be used to implement processes improvement. According to this model, the formation of the team should be the first step in implementing change using this method. The research on best practices for preventing falls and the data for falls specific to the unit are all responsibilities that can be assigned once the team is built. Creating a questionnaire is actually not recommended in the process unless it can be evaluated for reliability and validity.

The nurse is using data collected to monitor the outcomes of a clients on a surgical unit. Which competency is the nurse demonstrating? Patient-centered care Evidenced-based practice Quality improvement Safety

Quality improvement Rationale: The Quality and Safety Education for Nurses are competencies needed by nurses to provide quality, safe, and competent client care. Patient-centered care focuses on the client as a full partner in their care with the nurse providing compassionate and coordinated care. Evidenced-based practice integrates the most current research into practice. Quality improvement uses data to monitor client outcomes, which then can be used to improve delivery of care.

The nurse is caring for a client who asks the nurse to use a treatment method that the client read about on the internet. Which of the following responses by the nurse would be most appropriate? "You shouldn't really use the internet for health care information. Most of it is incorrect." "Can you tell me more about the website where you read the information?" "I am willing to give it a try. Does it say what the success rate is for using this treatment?" "Why are you questioning your doctor's order? She is an expert in the field.

Rationale: Clients are internet savvy and often search the internet for medical information about their conditions and request information from others using social media. Since there is a lot of information on the internet, clients need the expertise of nurses and other health care providers to direct clients to information that are reliable, current and evidence-based. Many health care organizations have a list of vetted mobile apps and internet sites clients can use. Rationale: Clients are internet savvy and often search the internet for medical information about their conditions and request information from others using social media. Since there is a lot of information on the internet, clients need the expertise of nurses and other health care providers to direct clients to information that are reliable, current and evidence-based. Many health care organizations have a list of vetted mobile apps and internet sites clients can use. Asking the client an open-ended question about the origin of the information is a therapeutic communication approach and allows the nurse to determine the quality of the information and demonstrate respect for the client's autonomy. The other responses are non-therapeutic and will most likely make the client feel guilty for taking the initiative to learn more about their health.

The home health nurse is developing a plan of care for a child with Duchenne muscular dystrophy. Which other disciplines should the nurse consider collaborating with to slow the progression and prevent complications of the disease? Select all that apply. Physical therapy Orthopedist Pulmonologist Dietitian Speech therapy Nephrologist

Rationale: Duchenne muscular dystrophy (DMD) is the most severe and common muscular dystrophy caused by a genetic mutation that results in the degeneration of muscle fibers. The disease is progressive, causing weakness and wasting of skeletal muscles and resulting in disability and deformity. Clinical manifestations include trouble getting into a sitting or standing position, difficulty walking, frequent falls, and delayed growth. Complications of DMD include respiratory compromise, cardiac failure, disuse atrophy, and contractures. The goal of care is to slow the progression of the disease and implement interventions to help prevent complications. The care team should include physical therapy, speech therapy, cardiology, pulmonology, orthopedist, and a dietitian. Nephrology is not part of the care team for the management of DMD.

The nurse enters the room of a client and finds them unresponsive and pulseless. Which of the following interventions would be appropriate to delegate to the unlicensed assistive personnel? Notifying the provider Scanning the medications administered Performing chest compressions Evaluating the client's heart rhythm

Rationale: The unlicensed assistive person (UAP) can perform chest compressions during a cardiac arrest. Delegating this task to a UAP is ideal so that the registered nurses can perform other necessary tasks. UAPs cannot administer or document medications in the medical record or assess the client's heart rhythm. They also should not be responsible for notifying a provider about a client status change.

The nurse is caring for a client who has an order for continuous bladder irrigation. The nurse does not perform this procedure frequently and is unsure which supplies are needed. Which action by the nurse is appropriate? Read the facility's bladder irrigation procedure Ask another nurse to initiate the irrigation Delay the irrigation until the next shift Manually flush the catheter with normal saline

Read the facility's bladder irrigation procedure Rationale: If the nurse is unsure of any part of the procedure, the best action is to pull the facility policy to ensure that the appropriate supplies used and steps are done correctly. While asking another nurse to initiate the irrigation may accomplish the task, the nurse still needs education on the procedure. Delaying this procedure may result in complications for the client, and manually flushing the catheter does not satisfy this prescription.

The nurse is gathering supplies to insert an intravenous (IV) line when they notice that the supply kit contains a new type of antiseptic for skin prep. Which action by the nurse is most appropriate? Performing the IV start as usual Asking a fellow nurse if they have used the new product Reading the antiseptic manufacturer's instructions Tell the supervisor that the staff will need training

Reading the antiseptic manufacturer's instructions Rationale: Any time that a nurse needs to use new product or supply, it is important that they familiarize themselves with the manufacturer's instructions on proper use. The nurse should not perform the skill as usual because there may be a need to change current practice when a different product is used. Asking another nurse if they have used the product does not provide the nurse with proper instructions on how to use the new supply. While training may be necessary, telling the supervisor does not immediately address the need to perform the IV start.

The charge nurse is planning to make the staffing assignments for the next shift. Which action by the charge nurse will ensure continuity of care for a client with complex needs? Choose the nurse with the most experience to this client. Reassign the nurse that cared for the client yesterday. Assign the nurse who has been off for several days. Collaborate with the staff to determine who would like to care for the client.

Reassign the nurse that cared for the client yesterday. Rationale: Continuity of care is a process by which healthcare providers give appropriate, uninterrupted care. Continuity depends on excellent communication as clients move from one caregiver or health care site to another. Have consistent nursing care by the same individuals promotes continuity. Choosing the nurse with the most experience may ensure things are done correctly but does not promote continuity.

The unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature of a post-surgical client is a 101°F (38.3°C). An hour ago the client's temperature was 99°F (37.2°C). Upon entering the client's room, the nurse observes a cup of hot coffee at the bedside. Which instructions are appropriate for the nurse to give to the UAP? Chart this temperature elevation on the flowsheet, and retake the temperature in 2 hours Provide the client with only cold water and juices to drink every hour Encourage the client to drink more oral fluids to prevent dehydration Recheck the oral temperature 15 minutes after removing the hot coffee from the bedside

Recheck the oral temperature 15 minutes after removing the hot coffee from the bedside Rationale: A recheck of the oral temperature is needed to eliminate the possibility of an artificial elevation of temperature from the hot coffee. Hot or cold liquids, smoking, eating, chewing gum, and talking can all elevate or lower the temperature if done within 10 minutes of the temperature being taken. Waiting to take the temperature for 15 minutes will help the temperature return to its normal reading and facilitate an accurate reading. The nurse should avoid premature assumptions about explanations for findings, and the initial action is to do an assessment of the client.

The new nurse understands that patient-centered care, according to QSEN, should include which nursing actions? Select all that apply. Adhering to Institutional Review Board (IRB) guidelines. Recognizing the boundaries of therapeutic relationships. Respecting and encouraging individual expression of client values. Communicating what care was provided and is needed at each transition in care. Participating in designing systems that support effective teamwork.

Recognizing the boundaries of therapeutic relationships. Respecting and encouraging individual expression of client values. Communicating what care was provided and is needed at each transition in care. Rationale: The QSEN project defines the knowledge, skills and attitudes (KSAs) for six key areas or required competencies for new nurses. KSAs required for patient-centered care include for the nurse to: Elicit patient values, preferences and expressed needs as part of the clinical interview, implementation of care plan and evaluation of care; communicate patient values, preferences and expressed needs to other members of the health care team; and provide patient-centered care with sensitivity and respect for the diversity of human experience. Designing systems that support effective teamwork fits under the Teamwork and Collaboration QSEN category. Adherence to IRB guidelines is found under the Evidence-based Practice (EBP) QSEN competency.

The nurse is caring for a 69-year-old client who is experiencing hyperglycemia. Which activity or task is appropriate to delegate to the unlicensed assistive personnel (UAP)? Record dietary intake Review the initial signs of hyperglycemia with the client's family Monitor the client for altered levels of consciousness (LOC) Assess the condition of the client's skin on the lower extremities

Record dietary intake Rationale: The UAP can perform routine activities with predictable outcomes, such as recording dietary intake. Although the UAP can usually assist clients with personal hygiene and would be able to identify a change in LOC (for example, the client does not respond appropriately to questions), their role is to inform the nurse about changes in the client's condition. The nurse must follow up on this information and perform a focused assessment, communicate changes in the client's condition with the health care team, and then develop a revised plan of action for client care.

The hospital case management nurse is reviewing the medical record of an 86-year-old client who is scheduled to transfer to a transitional care program after discharge from the hospital. The client has had four inpatient hospitalizations in the last 2 months. What is the primary purpose of the transitional care program? Reduce readmissions to the hospital Reduce insurance cost Provide respite for the client's spouse Increase satisfaction with nursing care

Reduce readmissions to the hospital Rationale: Transitional care, or the care clients receive as they move between health care settings, involves bridging care gaps across different health care settings, including hospitalizations and outpatient visits. Hospital-based transitional care interventions aim to smooth the transition from the inpatient to the outpatient setting and prevent unnecessary readmissions and adverse events. Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The client clearly has had frequent hospitalizations and would very likely benefit from a transitional care program.

The nurse is planning discharge care for a client with a BMI of 32 and uncontrolled hypertension who had a myocardial infarction. Which resource would be the priority for this client? Refer the client to a support group of clients with hypertension Refer the client to a cardiac rehabilitation unit Refer the client for home health services to reinforce medication adherence Refer the client to a personal trainer to increase exercise to 60 minutes/day

Refer the client to a cardiac rehabilitation unit Rationale: Cardiac rehabilitation includes progressive exercise, diet teaching, and classes on modifying risk factors. This supervised setting would be the priority intervention for this client in the plan of care. The client should be encouraged to exercise, but it should be in a supervised setting such as cardiac rehabilitation, not with a personal trainer due to the client's condition and pre-existing conditions (i.e., hypertension). This client would also benefit from diet teaching, which is included in cardiac rehabilitation to reduce weight. Although medication adherence is important, it is not a priority intervention. Support groups bolster the client's emotional strength but are not a priority intervention.

The nurse is preparing to administer for the first time a prescribed medication to a client. What is the initial action the nurse should take prior to administering this medication for the first time? Ask an experienced nurse who is familiar with the medication regarding adverse effects of the medication. Contact the healthcare provider. Refer to a drug handbook for safe dosage considerations. Check with the client regarding the accuracy of the medication.

Refer to a drug handbook for safe dosage considerations. Rationale: A nurse must be knowledgeable about a medication before administering it to a client. The initial action of the nurse would be to consult a nursing drug handbook which would include information about the drug's expected action, usual dosage, adverse effects, and nursing considerations. An experienced nurse who is familiar with the medication may be consulted after the nurse looks up the medication in the drug handbook. It is not reliable to refer to the client regarding the medication. While many clients are very knowledgeable, nurses should not assume this. The healthcare provider would be contacted if the nurse had questions regarding the dosing, action, or adverse effects of the medication as prescribed.

The clinic nurse is reviewing the laboratory results for a client who is postoperative gastric bypass surgery. The nurse notes the client's WBC of 7,000 per microliter, serum glucose of 102 d/L, vitamin D level of 30 ng/mL, ferritin level of 200 mcg/L, and a serum albumin of 25 g/L. The nurse should request a referral to which member of the healthcare team for this client? Registered dietitian Infectious disease practitioner Endocrinologist Social worker

Registered dietitian Rationale: A registered dietitian (RD) manages and plans for the dietary needs of patients, based on knowledge about all aspects of nutrition. RDs can adapt specialized diets for the individual needs of patients, counsel, and educate individual patients. This client is demonstrating protein malnourishment based on the serum albumin level. Therefore, the dietitian should be informed. All other lab work is normal. The social worker may be needed later on, but it not initially needed in the development of the plan of care.

There is an order for a 25-year-old client, who is unresponsive after suffering a traumatic brain injury, to be transferred from the hospital to a long-term care facility today. Which staff member should the charge nurse assign to care for this client? Registered nurse (RN) Licensed practical nurse (LPN) Unlicensed assistive person (UAP) Nursing student in final semester before graduation

Registered nurse (RN) Rationale: The Registered Nurse (RN) is responsible for facilitating continuity of care for clients and their families during the transfer from one health care setting to another. The transfer to a long-term care facility often requires referrals and coordinating information from many different providers about treatments, therapies and medications. The charge nurse should assign this client to a RN.

While a client is attending a physical therapy session, the nurse observes an unlicensed assistive personnel (UAP) trying on a client's jewelry. What is the most appropriate action by the nurse? Report the incident to the client and family. Reinforce facility policy on safeguarding client valuables with the UAP. Notify the nursing supervisor. Remind client and family not to leave valuables unattended.

Reinforce facility policy on safeguarding client valuables with the UAP. Rationale: Nurses are responsible for safeguarding and respecting clients' personal possessions and valuables; they must also not, under any circumstances, borrow or steal their personal possessions and valuables. The UAP should first be updated on facility policy rather than report the incident to the family. Although policies and procedures relating to the safeguarding of clients' personal possessions and valuables may vary a little from one healthcare facility to another, these policies and procedures typically include discouraging clients to retain personal possessions and valuables while hospitalized, and then securing maintained and retained personal possessions and valuables in a locked and secure safe.

The nurse is caring for a client who is two days post-reconstructive nasal surgery. Which task would be most appropriate to delegate to the unlicensed assistive person (UAP)? Observe for restlessness or changes in breathing patterns Suggest that the client ask for pain medication every few hours Remind the client to report increased pain or changes in comfort Ask the client if the medication for pain was effective

Remind the client to report increased pain or changes in comfort Rationale: Any activity that requires independent, specialized nursing knowledge, skill or judgement cannot be assigned to the UAP. Only the RN can assess and evaluate the client's level of pain or teach the client about pain management. However, the UAP can reinforce the nurse's teaching about pain management.

The charge nurse observes a new nurse inserting an indwelling urinary catheter on a female client who is experiencing urinary retention. After the nurse inserts the catheter, no urine outflow appears. Which action should the charge nurse take? Remove the catheter and have the nurse get a new catheter and insertion kit. Remove and re-lubricate the catheter and assist the nurse with re-insertion. Leave the catheter in place and check for urine output in 15 minutes. Ask the nurse to withdraw and redirect the catheter anteriorly toward the pubic bone.

Remove the catheter and have the nurse get a new catheter and insertion kit. Rationale: If no urine appears after inserting a catheter into a female client, the catheter may be in the vagina. The nurse should calmly remind the nurse about this circumstance and offer assistance. This client is experiencing urinary retention, so urine outflow should occur immediately with catheter insertion. It would not be appropriate to leave the catheter in when there is no outflow. No outflow suggests the catheter is not in the urethra. The nurse should remove the catheter and retrieve a new catheter and insertion kit; then the charge nurse should assist with correct catheter insertion. A catheter that has been inserted into the vagina should not be redirected into the urethra. This can lead to a urinary tract infection for the patient. A new catheter should be used with each insertion attempt.

A client is scheduled for a transesophageal echocardiogram (TEE). Prior to the procedure, which activity could be delegated to the unlicensed assistive person (UAP)? Provide basic instructions about the procedure Obtain a signed consent Assess the client's psychological state Remove the pitcher of water from the bedside table

Remove the pitcher of water from the bedside table Rationale: Removing the water pitcher would be an appropriate task because the client would be NPO. The health care provider is responsible for instructions about the procedure and needs to address client questions or concerns. The nurse is typically responsible to obtain a signed consent form and to assess the client both physically and psychologically before the procedure.

The nurse and unlicensed assistive personnel (UAP) are caring for clients in the labor and delivery unit. Based on scope of practice, which action would be delegated to the unlicensed assistive personnel (UAP)? Teaching a client how to breastfeed her infant Removing a fetal monitor and assisting the client to the bathroom. Checking for deep vein thrombosis while ambulating the client Palpating the fundus and perform gentle fundal massage

Removing a fetal monitor and assisting the client to the bathroom. Rationale: Removing a fetal monitor from a client and assisting her to the bathroom is within the legal scope of practice of an unlicensed assistive personnel (UAP). Performing a fundal check, palpating the fundus, and performing fundal massage is a responsibility of a registered nurse. Checking extremities for the presence deep vein thrombosis is an assessment skill performed by the registered nurse. Education is also part of the professional nursing role. Although a UAP can assist a mother with breastfeeding, the formal client education must be completed and validated by the nurse.

The nurse is planning care for a client admitted with uncontrolled hyperglycemia. Which activities can the nurse delegate to the unlicensed assistive person (UAP)? Select all that apply. Apply moisturizing cream between the client's toes. Report any skin lesions or breakdown to the nurse. Cut the client's toenails short and trim the corners with cuticle scissors. Soak the client's feet in warm water prior to performing nail care. After bathing, ensure that the client's skin is completely dry. Check the client's blood sugar before meals and at bedtime. Administer insulin, but do not aspirate for blood prior to injecting.

Report any skin lesions or breakdown to the nurse. After bathing, ensure that the client's skin is completely dry. Check the client's blood sugar before meals and at bedtime. Rationale: When collaborating with the UAP, it is important to delegate activities that are appropriate for the UAP to perform and appropriate for the client and their condition. In clients who suffer from diabetes, blood sugar monitoring, skin care and foot care are essential. The UAP should check the client's blood sugar before meals and at bedtime. However, the UAP should not administer insulin. While providing hygiene care, the UAP should dry the skin and apply moisturizing lotion. However, lotion should not be applied between the toes due to the risk of macerating injuries. When providing foot care, soaking the feet is contraindicated and nails should be cut straight across to prevent injury

The nurse is planning care for a newly admitted 78-year-old client who is diagnosed with severe dehydration. Which task would be appropriate for the nurse to assign to an unlicensed assistive person (UAP)? Monitor client's ability for movement in the bed from side to side. Check skin turgor every 4 hours and change the client's adult diaper. Report hourly outputs of less than 30 mL/hr within 15 minutes of the check. Converse with the client to determine if the mucous membranes are impaired.

Report hourly outputs of less than 30 mL/hr within 15 minutes of the check. Rationale: When assigning tasks to an unlicensed assistive person (UAP), the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the nurse is responsible for all care-related decisions, only routine tasks should be assigned to UAPs because such tasks do not require clinical judgment and decision-making. Measuring hourly urine output and reporting the amount to the nurse is an appropriate task to delegate to a UAP.

A staff nurse on a busy inpatient hospital unit observes a coworker placing a syringe with an opioid medication into their pocket and going into an empty patient room. Which is the best action for the nurse to take? Wait until things quiet down and then talk to the coworker about getting help. Ask another staff member for advice on what to do. Follow the coworker and confront them about their addiction. Report the observation to the nursing supervisor immediately.

Report the observation to the nursing supervisor immediately. Rationale: Although the nurse's observation appears to point toward a coworker who might be diverting opioids, it is presumptive to jump to the conclusion that the coworker's action is malicious. The best course of action is to follow facility protocol which typically consists of notifying the next person in the chain of command such as a manager or supervisor. This should be done immediately to give that person the opportunity to come to the unit right away and assess the situation. If it turns out that the nurse's coworker appears impaired, they should be immediately removed from the patient care area and drug tested.

A nurse is providing care to a client who has a pending discharge prescription from the previous day. The client is uninsured and requires total care. The client's family has refused to learn care and tells the nurse the hospital is responsible for the client's treatment. Which action does the nurse take? Provide the discharge instructions to the client's family. Request the discharge prescription be discontinued by the healthcare provider. Arrange home transportation for the client upon discharge. Report the situation to the interdisciplinary team.

Report the situation to the interdisciplinary team. Rationale: The nurse should report the situation to the interdisciplinary team. The family's refusal to learn care can impact the client's safety post-discharge. The nurse has a duty to explore all resources available to the client and the family. Providing discharge instructions to the client's family disregards the refusal to learn total care. Requesting the discharge prescription be cancelled is not cost-effective nursing care if the client is medically stable. Arranging home transportation for the client does not address the family's refusal to learn client care.

The nurse is caring for a client that requires peritoneal dialysis. The nurse has not performed this skill before. What is the best action by the nurse to ensure safe care? Contact the unit educator for guidance during the procedure. Initiate the dwell portion of the peritoneal dialysis procedure. Request a different client assignment and need for further education. Defer the procedure to a more experienced nurse on the oncoming shift.

Request a different client assignment and need for further education. Rationale: The nurse recognizes the lack of knowledge, skill, and competency to perform peritoneal dialysis and needs further education. Gaining the appropriate knowledge, skill, and competency to complete this skill will require further education and practice, not just a bedside session. The other options are incorrect because they are neither appropriate nor safe and do not address the nurse's need for further education.

A nurse is providing care to a client with a language barrier. The client tells the nurse they did not understand the updated plan of care provided by the healthcare provider during rounds. Which action does the nurse perform? Call the client's family, and request a family member at the bedside Instruct the client to write down any concerns, and inform the nurse supervisor Review abnormal laboratory results, and share the information with the client Request a medical interpreter, and contact the healthcare provider

Request a medical interpreter, and contact the healthcare provider Rationale: The client has the right to understand all aspects of their medical care. It is a nurse's duty to provide the client with all necessary resources to ensure understanding of their plan of care. The nurse contacts the healthcare provider and ensures a medical interpreter is available. A family member should not translate for the client, particularly if medical terminology is not known. Escalation of the client's concerns should be directed to the healthcare provider with the aid of a medical interpreter. Sharing abnormal laboratory data with the client that has not been reviewed by the healthcare provider is outside the nurses' scope of practice.

The nurse is preparing an admission assessment for a client diagnosed with roseola. Which action should the nurse take initially? Initiate oxygen therapy. Request a private room with negative airflow pressure. Notify staff of need for personal respiratory protection mask. Assess need for suction equipment.

Request a private room with negative airflow pressure. Rationale: Roseola (measles) is transmitted via airborne droplets. The initial action the nurse should make on assessment for supplies for a client with known airborne infection is to provide a private negative airflow pressure room to decrease incidence of transmission. It is important to notify the staff of need for personal respiratory protection mask (e.g., N95 respirator), but not the initial action. The initiation of oxygen therapy and suction setup may be needed for this client with a respiratory compromise, but safety and isolation is the initial action by the nurse to prevent transmission of infection.

A nurse receives a chest physiotherapy prescription for a client who is unable to clear their respiratory secretions. After performing manual percussion, the nurse does not observe adequate airway clearance in the client. Which action does the nurse perform next? Document the treatment as being unsuccessful. Continue performing the procedure until the client clears their secretions. Educate the client on coughing and deep breathing. Request a referral to respiratory therapy.

Request a referral to respiratory therapy. Rationale: Chest physiotherapy is a skill that can be performed using percussion or vibration. Respiratory therapists are skilled in providing treatments to aid in airway clearance. A referral to respiratory therapy is indicated. Documentation of the procedure is important; however, the nurse must seek further resources to help the client clear their airway. Chest physiotherapy applies increased pressure to the chest wall. Extending the length of the procedure may cause injury. Educating the client on coughing and deep breathing promotes lung expansion and may help mobilize secretions; however, this intervention does not meet the goal of chest physiotherapy.

A nurse is providing care to a client who is unconscious following a motor vehicle accident with significant internal bleeding. After the healthcare provider discusses life-sustaining measures, the client's spouse refuses a blood transfusion due to religious reasons. Which action does the nurse take next? Refer the case to the ethics committee. Respect the wishes of the client's spouse. Request for the healthcare provider to discuss alternative treatment. Document the spouse's refusal of treatment for the client.

Request for the healthcare provider to discuss alternative treatment. Rationale: The nurse should request for the healthcare provider to discuss alternative treatment options with the client's spouse. The nurse must still advocate for the client while respecting the wishes of decision-makers. Referring the case to the ethics committee is not indicated until after all options have been discussed with the client's spouse. Respecting the wishes of the client's spouse without discussing alternative life-sustaining options does not advocate for the client. Documenting the spouse's refusal of treatment for the client should occur until all alternative treatment options are discussed.

The nurse is caring for a client who has a thoracentesis and physical therapy scheduled during the nurse's shift. Which action by the nurse is most appropriate to effectively manage this client's care? Request that the client's physical therapy be performed in the morning Cancel the client's physical therapy prescription for that day Ensure that the thoracentesis is performed before physical therapy begins Medicate the client with analgesics prior to both activities

Request that the client's physical therapy be performed in the morning Rationale: The most appropriate action would be to request that the physical therapy be performed in the morning prior to the thoracentesis. This action still allows both prescriptions to be completed but in the most effective way. Canceling the physical therapy and planning to complete the physical therapy after the thoracentesis are not the most effective management of care strategies. Medicating the client prior to these activities is not an incorrect action but does not address the schedule conflict.

A nurse reviews a discharge home prescription for a client with a traumatic brain injury. The client is unable to perform activities of daily living independently and lives with elderly parents. Which action does the nurse perform? Coordinates the client's transportation home after discharge Provides discharge instructions to the client's parents Instructs the client's parents to hire a caregiver upon discharge Requests a consult to social work for discharge placement

Requests a consult to social work for discharge placement Rationale: The nurse's role as an advocate is to assess the safety of a client's discharge. A client who is unable to perform activities of daily living independently is not safe to discharge home with elderly parents who may be unable to provide safe care. The nurse requests a consult to social work for possible discharge placement. The client's transportation home is not the priority issue at this time. Providing discharge instructions to the client's parents finalizes the discharge. The nurse must first assess discharge safety. The nurse should coordinate with the healthcare team to provide available resources to the client and their family upon discharge.

A nurse is precepting a graduate nurse who is providing care to a client with a language barrier. The healthcare provider prepares to discuss the plan of care with the client. Which action by the graduate nurse indicates an understanding of the client's rights? Ensures the client's family is available to translate Requests a medical interpreter for the client Instructs the client to ask questions if clarification is needed Provides a written summary of the plan of care in the client's language

Requests a medical interpreter for the client Rationale: Clients have the right to understand all aspects of their medical care. A client with a language barrier requires an interpreter to assist with translating information being delivered by the healthcare team. A family member should not be used to translate medical information. The client requires an interpreter with knowledge of medical terminology. All clients have the right to ask clarifying questions. However, this does not address the language barrier. Providing a written summary does not allow the client to be actively engaged in a conversation with the healthcare provider about their plan of care.

The nurse in an emergency room is planning care for a client who is unconscious and arrived by ambulance from a long-term care facility. The paramedics have given the nurse copies of paperwork from the client's facility. Which is the best way for the nurse to determine who should make health care decisions for this client? Call the emergency contact person listed in the client's paperwork. Contact the client's primary care physician by phone. Review a notarized original copy of the client's advance directives. Ask the primary health care provider in the emergency room.

Review a notarized original copy of the client's advance directives. Rationale: The client's advance directives specify the client's wishes about what actions are to be taken should the client become unable to make health care decisions. This client is unconscious, thus unable to make decisions. Typically, clients from long-term care facilities have advance directives in place, and the facility sends this document with them if they leave the facility for any reason. The advance directive often includes a living will and the power of attorney to whom will make the health care decisions for the client. The nurse should seek out this document when planning care for this client to ensure the client's wishes are followed.

The nurse is planning out the daily tasks for assigned clients. Which of the following actions by the nurse should be completed first to manage time effectively? Explain the procedures to each client Gather all necessary supplies for interventions Review the client's prescriptions in the medical record Request that the nursing supervisor assist with tasks

Review the client's prescriptions in the medical record Rationale: The nurse should first review all of the client's prescriptions before beginning to complete tasks. This action allows the nurse to plan what interventions can be clustered together and/or what tasks need to be prioritized. Gathering supplies and explaining procedures would occur after the nurse has reviewed the medical record and requesting help from the nursing supervisor might occur if the nurse realizes that assistance is needed.

The nurse is participating in a quality improvement (QI) project with a focus on improving pain management on a surgical unit. Which actions should be included in this QI project? Select all that apply. Reviewing pain management protocols for evidence-based practice Developing a team approach for the entire health care team to participate in the process Designing a research study to produce evidence supporting the current protocol Determining pain management interventions proposed by the pharmacy department Reviewing client satisfaction data related to pain management

Reviewing pain management protocols for evidence-based practice Developing a team approach for the entire health care team to participate in the process Reviewing client satisfaction data related to pain management Rationale: Generally, quality improvement (QI) projects are directed at improving processes and client outcomes. For this particular project, actions are focused on pain management and should include reviewing evidence-based practice and client satisfaction surveys in relation to pain and pain management. A critical component of QI is teamwork and the team should include many different members of the health care team and not just a particular team member or department. A QI project is not the same as a traditional, quantitative research study.

The nurse is evaluating the time management skills of staff members. Which action by the staff member demonstrates effective time management? Asking the unit manager to complete some of the assigned tasks Delaying non-essential tasks until the next shift Documenting all nursing interventions after the shift has concluded Reviewing the clients' prescriptions before beginning to see clients

Reviewing the clients' prescriptions before beginning to see clients Rationale: The nurse should review all of the clients' prescriptions before beginning to complete tasks. Doing this ahead of time allows the nurse to plan which interventions can be prioritized. Delaying tasks until the next shift and documenting after the normally scheduled shift are not appropriate time management techniques. Asking the unit manager for help is not an indicator of time management.

The nurse is present when the healthcare provider obtains consent for a surgical procedure. What information does the nurse anticipate will be provided to the client? Risks, benefits, and alternatives of the intervention Names of the healthcare providers who will be present for the procedure Types of medications administered during the procedure Number of people who undergo the procedure each year

Risks, benefits, and alternatives of the intervention Rationale: Informed consent is the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. The Joint Commission requires documentation of all the elements of informed consent "in a form, progress notes or elsewhere in the record." The following are the required elements for documentation of the informed consent discussion: (1) the nature of the procedure, (2) the risks and benefits and the procedure, (3) reasonable alternatives, (4) risks and benefits of alternatives, and (5) assessment of the patient's understanding of elements 1 through 4. The other options are not components of informed consent although this information may be discussed.

The nurse is caring for a client who is post-operative right knee arthroplasty and has a prescription for physical therapy and occupational therapy. Which of the following actions by the nurse is appropriate? Ask the case manager to remind the therapists. Notify the therapists during the next multidisciplinary meeting. Seek out the therapists at the beginning of the shift to schedule therapy. Rely on the entry into the electronic health record as the mode of communication with the therapists.

Seek out the therapists at the beginning of the shift to schedule therapy. Rationale: Priority setting in nursing is based on meeting a client's unmet needs in a timely way. It is inappropriate to delegate the scheduling of inpatient therapy to the case manager. The nurse should not wait for the next meeting to inform the therapists as this will potentially delay care. While the electronic health record is designed as a form of communication, it is important to maintain interpersonal communication to promote teamwork.

During a lunch break, nurse colleagues discuss their nursing practice. Which of the following statements best represents nursing practice guidelines? The healthcare agency is ultimately responsible for developing practice guidelines for licensed nurses. National nursing associations are responsible for developing specific regulations for licensed registered nurses (RNs) and licensed practice nurses (LPNs). Specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) will vary from state to state. The federal government ensures the safety of clients by developing nursing practice guidelines.

Specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) will vary from state to state. Rationale: Nursing guidelines and regulations are developed to protect those who are receiving care. It is the state's duty to ensure licensed nurses provide safe, competent nursing care. Boards of nursing are state governmental agencies that are responsible for licensing nurses in each state and enforcing the rules and regulations of the nurse practice act. Nursing scope of practice may vary from state to state. It is the responsibility of the licensed nurse to be aware of their state's scope of practice. The other statements are not true in regards to nursing practice guidelines.

The nurse is documenting on the plan of care of a client who had a right total knee replacement. The nurse is utilizing a clinical pathway for the client's care. Which should the nurse identify as the purpose of a clinical pathway? Provide client information for the healthcare team. Identify critical information about the client's condition. Standardize expected client outcomes based on clinical guidelines. Provide a diagram to organize data to identify client problems.

Standardize expected client outcomes based on clinical guidelines. Rationale: There are different formats to develop and document the client's plan of care. A concept map care plan uses a diagram to represent client problems and interventions and is organized by client data. Change of shift reports focuses on the critical client information being communicated between nurses for continuity of care. Computerized care plans are accessible by anyone on the healthcare team to access client information. Clinical pathways are standardized, interdisciplinary care based on evidenced-based clinical guidelines for a specific condition or illness.

The nurse is performing discharge teaching to the parent of a pediatric client about supplemental feedings via a gastrostomy tube (GT). The nurse begins the process by teaching the parent which actions first? Steps to administer feedings Maintenance of equipment Cleaning insertion site Signs of complications

Steps to administer feedings Rationale: The parents' ability to maintain their child's nutrition is essential to the child's well-being. It is the priority action in teaching to make sure the parents know the steps to safely administer feedings. After this skill is acquired and verified by a return demonstration to the nurse, then proper cleaning of the site, maintenance of the equipment, and signs of complications can be taught.

The registered nurse and an experienced licensed practical nurse (LPN/VN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN/LVN? Provide discharge instructions to the spouse of a confused client Straight catheterize a client who has not voided in 8 hours Develop a plan of care for a client who is recovering from an appendectomy Complete the admission assessment for a client with diverticulitis

Straight catheterize a client who has not voided in 8 hours Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Professional nurses are responsible for delegating nursing activities, but although RNs may delegate elements of care, they do not delegate the nursing process itself. Nursing care or tasks that should never be delegated, except to another RN, include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated should be based on the training and competence of the individual accepting the delegation. The LPN/LVN scope of practice and training includes performing straight catheterization.

A nurse is performing client rounds with a healthcare provider on the unit. The healthcare provider assesses a client who had a stroke and has difficulty performing fine motor movements with the hands. Which priority action does the nurse take? Document the assessment findings in a progress note. Verify the client's prescriptions with the healthcare provider. Suggest a referral to occupational therapy. Encourage the client to ask questions regarding their plan of care.

Suggest a referral to occupational therapy. Rationale: The client would benefit from a referral to occupational therapy. Occupational therapists help clients regain motor skills after an illness or procedure. Documentation of the observations is important; however, the nurse must ensure the client is referred to the appropriate resource first. Verification of the client's prescriptions with the healthcare provider and encouraging the client to ask questions about their plan of care is standard for every client.

The nurse is caring for a group of hospitalized clients. The nurse has several tasks to delegate to the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to perform first? Take a blood specimen to the laboratory Transport a client to the radiology department for an X-ray Pass out fresh water to the clients Obtain a urine sample for a newly admitted client

Take a blood specimen to the laboratory Rationale: The work of setting priorities demands careful clinical reasoning. When using the urgent vs. non-urgent approach to prioritizing client care, the nurse should determine that the priority action is to take the blood sample to the laboratory. Over time, the specimen will deteriorate due to coagulation and lysis, making any results inaccurate and potentially delaying treatment. All other options are important, but bloodwork is the priority.

The nurse is caring for a pediatric client admitted to the ED with a dislocated shoulder. When asked how this occurred, the client states, "I tripped and fell down the stairs." What action will the nurse perform next? Talk with the client's parents to get additional details about the injury Contact the nursing supervisor, and call the police Contact Child Protective Services to report the injuries Continue to probe the client about specific details of the injury

Talk with the client's parents to get additional details about the injury Rationale: A nurse who suspects child abuse should talk with the parents and get additional details about the injuries and compare their story with that of the child before mandatory reporting for child abuse occurs. Telling the nursing supervisor to call the police or contacting Child Protective Services isn't the best action to take at this time. If further investigation continues to raise questions about abuse, these steps may be appropriate. The nurse does not need to continue to probe the client about details of the injury.

A nurse in a rural community uses telehealth to provide care and education to clients in remote locations. What are the perceived benefits of using telehealth? Telehealth empowers clients to take a greater interest in their illness. Telehealth removes the time and distance barriers from the delivery of care. Telehealth standardizes electronic sharing of health information data. Telehealth greatly reduces health care costs for the clients who use it.

Telehealth removes the time and distance barriers from the delivery of care. Rationale: Telehealth is the use of technology to deliver health care, health information or health education at a distance. People in rural areas and homebound clients can communicate with primary health care providers via telephone, email or video consultation, thereby removing the barriers of time and distance for access to care.

A nurse is assisting a charge nurse who has attempted to start an IV multiple times on a client unsuccessfully. The client states, "My arm is in a lot of pain. Please stop." The charge nurse disregards the client's statement and continues to attempt IV access. Which action does the nurse take? Tells the client, "This is necessary for your medical treatment." Tells the charge nurse, "Let's give the client a break." Leaves the room and informs the nurse manager. Comforts the client and continues to assist the charge nurse.

Tells the charge nurse, "Let's give the client a break." Rationale: The nurse should suggest to the charge nurse to stop the IV attempts. The nurse must advocate for the client and respect their request to stop the procedure. Telling the client that the procedure is necessary for medical treatment disregards the client's pain and refusal to continue providing consent. Leaving the room to inform the nurse manager leaves the client unattended and allows the charge nurse to continue the IV attempts against the client's wishes. Comforting the client and continuing to assist the charge nurse disregards the client's concerns and refusal of treatment.

A nurse is assigned to triage clients who are brought to the emergency department after a bus accident. Which client would be cared for first? The 56-year-old with external rotation and shortening of the left lower extremity The 35-year-old with an abrasion on the right anterior and lateral side of the chest The 9-year-old with dilated pupils and cessation of breathing 10 minutes ago The 18-year-old who is diaphoretic and tachycardic and has a board-like abdomen

The 18-year-old who is diaphoretic and tachycardic and has a board-like abdomen Rationale: Triage categories used during a mass casualty incident often use color-coding to prioritize care. The person in greatest need of immediate care (category - red) is the person with a board-like abdomen because this would indicate internal bleeding. The next person requiring urgent care (category - yellow) would be the individual with the shortened leg that is externally rotated, indicating a probable broken hip. The person with the chest abrasions is not currently having any difficulty breathing and can have treatment delayed for hours or even days (category - green). The individual who stopped breathing 10 minutes ago and whose pupils are fixed and dilated would not be treated because this person has already died (category - black).

The nurse on a post-surgical unit observes an unlicensed assistive person (UAP) caring for a client who had a transurethral resection of the prostate (TURP). Which action by the UAP requires immediate intervention by the nurse? The UAP adjusts the rate of the irrigation bag for the client's continuous bladder irrigation. The UAP applies a moisture barrier cream to the client's excoriated perianal area. The UAP assists the client to the bathroom to shave his face with an electric razor. The UAP empties the indwelling catheter bag and records the amount of output.

The UAP adjusts the rate of the irrigation bag for the client's continuous bladder irrigation. Question Explanation Rationale: Unlicensed assistive personnel (UAP) can perform a number of delegated nursing tasks, such as emptying an indwelling urinary catheter bag, applying moisture barrier cream after peri-care, assisting a client to the bathroom and helping a client shave with an electric razor. The UAP should not complete tasks that require nursing assessment. Since adjusting the irrigation rate requires nursing assessment, it should only be done by the nurse.

The charge nurse assigns the unlicensed assistive personnel (UAP) to measure vital signs. Clear written and verbal instructions were given to the UAP not to take the blood pressure on the left arm of a client. The charge nurse later observes a blood pressure cuff on this client's left arm. Which of these statements is accurate? The UAP is covered by the charge nurse's license. The charge nurse did not appropriately make assignments. The charge nurse has no accountability for this situation. The UAP is responsible for following instructions given by the charge nurse.

The UAP is responsible for following instructions given by the charge nurse. Rationale: The UAP is responsible for carrying out the activity correctly once instructions have been clearly communicated verbally and in writing. The licensed nurse does retain accountability for the delegation of the assignment and the tasks assigned. Taking vital signs falls within the parameter of tasks that can be assigned to a UAP. The UAP is not covered under the nurse's license.

The nurse is caring for a client who is scheduled for surgery. The client is competent and neurologically intact. The nurse should inform the surgeon who will be providing informed consent? The client The person granted power of attorney for healthcare The legal next of kin The client's emergency contact

The client Rationale: Informed consent reflects a process of effective communication that results in the patient's voluntary agreement to undergo a particular procedure or treatment (such as surgery). A healthcare power of attorney states who should speak for the client if they are unable to make decisions for themselves. This client is competent to make their own decisions and should be involved in the informed consent process. A person's next of kin is their closest living blood relative whereas the emergency contact is someone the client specifies.

The nurse is administering several oral medications to a client with Parkinson's disease. Which observation would require the nurse to update the client's plan of care? The client begins to cough after taking a medication. The client takes one medication at a time. The client uses a straw to drink when taking a medication. The client has difficulty putting the medication in their mouth.

The client begins to cough after taking a medication. Rationale: Parkinson's disease is a progressive disorder that affects muscle movement. Clients with Parkinson's disease will have tremors, making it difficult to hold objectives or control movements. The nurse would need to update the plan of care if the client demonstrates complications. A client with Parkinson's disease who begins coughing after taking medication might be experiencing dysphagia and would require interventions to prevent aspiration.

A nurse is providing care to a client post ischemic stroke. Which client activity prompts the nurse to revise the care plan? The client tolerates ambulating 20 feet with a physical therapist. The client drops hygiene products while performing self-care. The client performs 2 range of motion exercises while in bed. The client clears their throat after each bite of a mechanical soft diet.

The client clears their throat after each bite of a mechanical soft diet. Rationale: A client with a stroke is at risk for dysphagia and aspiration. Constant throat clearing during mealtimes indicates the client's diet is not appropriate or safe. Ambulation with physical therapy is a safe intervention that promotes mobility and protects skin integrity. The distance ambulated is expected to gradually increase. Dropping objects may be an expected response to weak extremities following a stroke. Self-care should continue to be encouraged. Range of motion exercises help the client prevent skin integrity issues and promotes muscle strength. The nurse should continue to encourage the client's repetitions.

A nurse is providing care to a client with a bloodstream infection. Which situation would prompt the nurse to request an interdisciplinary conference with a pharmacist? The client develops a rash after the first dose of intravenous antibiotics. The client refuses to take the prescribed antibiotics. The client has history of antibiotic sensitive bacteria. The client develops c-diff after multiple prescribed antibiotics

The client develops c-diff after multiple prescribed antibiotics Rationale: C-diff is an infection caused by the destruction of normal flora in the large intestine. Antibiotic use is the primary cause of c-diff. An interdisciplinary conference with a pharmacist can help guide providers to prescribe the suitable pharmacological treatment. A rash is a sign of an allergic reaction. The nurse should notify the healthcare provider to report an allergic reaction. Client refusal of the medication does not require an interdisciplinary conference with a pharmacist. The nurse encourages the client to receive treatment and respects the client's wishes. A pharmacist collaboration is not indicated for bacteria that can be treated with antibiotics.

The nurse is providing an SBAR shift report on a client who is postoperative right knee replacement. Which of the following information should the nurse include in the assessment section of the report? The client has a prescription for ambulation. The client has a history of hypertension. The client will need a referral for home health care. The client has a dressing that is dry and intact.

The client has a dressing that is dry and intact. Rationale: SBAR is the standard format for providing and receiving a report on client care, which organizes client care into sections: situation, background, assessment, and recommendation. The situation section focuses on what is occurring with the client, such as prescriptions or interventions that need to be implemented. The background provides information on what caused the current situation and includes the client's past history. Assessment includes information about the nurse's impression of the problem, such as findings observed or measured by the nurse. Recommendation explains what would need to be done for the client, such as further referrals or follow-up care.

The nurse is caring for an adolescent who requires informed consent for a procedure. Under which circumstance can a minor client sign the consent? The client's guardian refuses to sign the consent. Both of the client's parents are deceased. The client has been deemed emancipated. The client is under the care of a foster family.

The client has been deemed emancipated. Rationale: Informed consent is a legal document that gives permission for invasive or high-risk procedures, such as blood transfusions and surgery. Informed consent for a procedure is signed by the provider performing the procedure, the client, and a witness. The legal age to give consent in the United States is 18. An emancipated minor is younger than the legal age to give consent but has been recognized to have the legal capacity to make an informed consent. The only situation a minor client can sign for consent is if they have been deemed emancipated. A minor cannot sign for consent if their guardian refuses. A minor whose parents are deceased or who is under the care of a foster family is assigned a legal representative who would sign the informed consent.

The nurse is caring for an adolescent who requires an informed consent for a procedure. Under which circumstance can a minor client sign the consent? The client's guardian refuses to sign the consent. Both of the client's parents are deceased. The client has been deemed emancipated. The client is under the care of a foster family.

The client has been deemed emancipated. Rationale: Informed consent is a legal document that gives permission for invasive or high-risk procedures such as blood transfusions and surgery. An informed consent for a procedure is signed by the provider performing the procedure, the client and a witness. The legal age to give consent in the United States is 18. An emancipated minor is younger than the legal age to give consent but has been recognized to have the legal capacity to make an informed consent. The only situation a minor client can sign for consent is if they have been deemed emancipated. A minor cannot sign for consent if their guardian refuses. A minor whose parents are deceased or who is under the care of a foster family is assigned a legal representative who would sign the informed consent.

A nurse is feeding a client with Parkinson disease. Which nursing observation indicates the client may benefit from a referral to speech therapy? The client tucks their chin while swallowing. The client chews the food quickly. The client has drooling of food. The client requests food to be pureed.

The client has drooling of food. Rationale: Drooling of food is an indication of possible dysphagia. The client would benefit from a referral to speech therapy for a safety assessment while feeding. Tucking the chin helps to move food down the esophagus and is good practice to prevent aspiration. Chewing the food quickly does not indicate a deficiency. The client requesting food to be pureed is an indication that they understand the risk of aspiration.

The nurse is caring for a client who is 28 hours post-operative following a total knee replacement. Which of the following assessment findings should the nurse report to the client immediately? The client has unilateral calf redness. The client reports increased knee pain with activity. The client has anorexia. The client's IV was pulled out during ambulation.

The client has unilateral calf redness. Rationale: Unilateral calf pain, redness, and swelling indicate a possible venous thromboembolism and should be reported to the provider immediately. Knee pain post knee replacement is a normal finding and should be managed with prescribed analgesics. While anorexia and accidental IV discontinuation are abnormal findings, they are not cause of significant concern.

The licensed practical nurse (LPN) from the pediatric unit is reassigned to work on an adult ortho-neuro unit. Which client assignment would be most appropriate for this nurse? The client in balanced traction admitted three days ago after a motor vehicle accident The client who is one day post total knee arthroplasty experiencing shortness of breath The client with a newly applied long leg cast experiencing uncontrolled pain The client who experienced a stroke and is ready to be transferred to a long term care facility

The client in balanced traction admitted three days ago after a motor vehicle accident Rationale: The licensed registered nurse (RN) can assign clients to the LPN as long as the care required is not too complex and there is a low likelihood of an emergency. The most stable client is the client in balanced traction who was admitted three days ago. The client experiencing shortness of breath and uncontrolled pain are unstable and need further assessment by the RN. Admitting or discharging a client is a complex process and requires the knowledge and skills of the RN.

The nurse is planning the discharge of an 80-year-old female client. Which of the following indicates the client needs to be discharged to a skilled nursing facility instead of home? Select all that apply. The client is not able to manage her activities of daily living (ADL). The client needs intensive rehabilitation after hip replacement surgery. The client is able to prepare simple meals by herself. The client has a complex surgical dressing change. The client is afraid to go home by herself.

The client is not able to manage her activities of daily living (ADL). The client needs intensive rehabilitation after hip replacement surgery. The client has a complex surgical dressing change. Rationale: After a hospital stay, the client may not be able to return to self-care at home, and referrals to a skilled nursing facility may be necessary. Some of the criteria for admission to a skilled nursing facility include not being able to manage her own ADL and requiring a complex dressing change. Intensive rehabilitation is better accomplished at a skilled nursing facility. Being afraid to go home by herself will need to be addressed prior to discharge but is not a criterion for admission to a skilled nursing facility. If the client is able to prepare her own meals, it is a sign that the client could stay at home.

The nurse is planning the discharge of an 80-year-old female client. Which of the following indicates the client needs to be discharged to a skilled nursing facility instead of home? Select all that apply. The client is not able to manage her activities of daily living (ADL). The client needs intensive rehabilitation after hip replacement surgery. The client is able to prepare simple meals by herself. The client has a complex surgical dressing change. The client is afraid to go home by herself.

The client is not able to manage her activities of daily living (ADL). The client needs intensive rehabilitation after hip replacement surgery. The client has a complex surgical dressing change. Rationale: After a hospital stay, the client may not be able to return to self-care at home and referrals to a skilled nursing facility may be necessary. Some of the criteria for admission to a skilled nursing facility include not being able to manage her own ADL and requiring a complex dressing change. Intensive rehabilitation is better accomplished at a skilled nursing facility. Being afraid to go home by herself will need to be addressed prior to discharge but is not a criterion for admission to a skilled nursing facility. If the client is able to prepare her own meals, it is a sign that the client could stay at home.

A nurse is providing care an older adult client who has a complex wound to the sacrum. Which client situation indicates the need for a referral to social work? The client will require oral antibiotics for several weeks The client lives with their spouse who has advanced dementia The client verbalizes uncontrolled pain to the lower back The client refuses to look at their wound during dressing changes

The client lives with their spouse who has advanced dementia Rationale: A client with a complex wound will require consistent wound care after discharge. A spouse who has dementia will be unable to provide the client with the treatment needed. The client would benefit from a referral to social work for community resources or discharge placement. Oral antibiotics do not require specialized arrangements or a referral to social work. Uncontrolled pain requires an adjustment to analgesic therapy. The nurse should contact the healthcare provider for prescription modification. The client's refusal to look at the wound during dressing changes does not indicate a need for a social work referral. The nurse should implement therapeutic communication and encourage the client to voice their concerns.

The nurse is reviewing the plan of care of a client who has prescription for discharge home. Which information is the priority for the nurse to report to the interprofessional team? The client reports living alone. The client ambulates with a walker. The client requires the daily wound dressing changes. The client attends weekly support group meetings.

The client requires the daily wound dressing changes. Rationale: The role of the nurse with discharge is to assess for a safe transition for the client. Healthcare providers, such as nurses, physical therapists, and dieticians, have specific roles that provide education, interventions, and support to clients. The nurse should report to the interprofessional team information that requires follow up by members of the team, such as the requirement of home equipment.

The nurse is caring for a client with a diagnosis of cirrhosis of the liver and ascites. What should the nurse emphasize to the unlicensed assistive personnel (UAP) about providing care for this client? The client is to ambulate as tolerated and be positioned in semi-Fowler's position when in bed. The client should ambulate as tolerated, resting in bed with legs elevated between walks. The client may ambulate and sit in a chair as tolerated. The client should remain on bed rest in the semi-Fowler's position.

The client should ambulate as tolerated, resting in bed with legs elevated between walks. Rationale: Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client to gradually increase the duration and frequency of walks.

A nurse is assessing a client with a left lower extremity fracture who has been prescribed crutches for ambulation. Which observation indicates the client may benefit from a referral to physical therapy? The client asks for assistance before getting out of bed and uses one crutch to stand. The client takes frequent breaks during ambulation and uses a four-point gait. The client grabs the hand grips and places their body weight on the axillae while ambulating. The client flexes their elbows and leans forward while holding the crutches.

The client takes frequent breaks during ambulation and uses a four-point gait. Rationale: Crutches are prescribed to prevent the client from placing weight on the affected extremity. A four-point gait indicates the client is placing weight on both lower extremities and might benefit from a referral to physical therapy for alternative options. Using one crutch to stand decreases balance. The client should be instructed to hold both crutches while standing. Weight should not be placed on the axillae while using crutches. The nurse should emphasize placing the weight on the hand grips. Leaning forward decreases balance. The client should be instructed to stand up straight while holding the crutches.

The nurse is developing the plan of care for a group of assigned clients. Which client should the nurse identify as having the highest risk of developing aspiration pneumonia? The client who is a resident of a long-term care facility The client who is prescribed immunosuppressive therapy The client who has a history of smoking cigarettes The client who has a head injury

The client who has a head injury Rationale: Aspiration pneumonia occurs when abnormal material, such as food, liquid, or bacteria, from the mouth or stomach enter the trachea and lungs. Clients who are at risk for aspiration pneumonia have a decreased level of consciousness, difficulty with swallowing, or have a nasogastric tube placed. A client with a decrease in level of consciousness, from a head injury, seizures, or anesthesia, can cause a depression of the client's cough and gag and reflex. Clients who are prescribed immunosuppressive therapy, smoke cigarettes, or are residents in long-term care facility are at risk for community-acquired pneumonia.

The nurse is caring for a group of surgical clients. Which of the following clients is not able to give informed consent? A client who received 5 mg of oxycodone 30 minutes ago The client who is withdrawing from alcohol intoxication A client who is a married minor The client who reads at the fourth-grade level

The client who is withdrawing from alcohol intoxication Rationale: Narcotic administration sufficient for pain control does not impair the ability to provide informed consent. Clients cannot give informed consent when they are very young or very ill, mentally impaired, demented or unconscious, or sometimes merely frail or confused. Emancipated (married) minors may give consent. The client with the lower reading level may require support but may sign their own consent. The client in alcohol withdrawal is potentially experiencing delirium and should not sign consent.

The nurse has received report on a group of assigned clients. Which client should the nurse assess first? The client with liver disease with a calcium level of 10.0 mg/dL The client with a fever with a sodium level of 136 mEq/mL The client who has a burn with a magnesium level of 2.0 mEq/L The client who reports muscle weakness with a potassium level of 6.1 mEq/L

The client who reports muscle weakness with a potassium level of 6.1 mEq/L Rationale: The nurse should see first the client with abnormal lab results exhibiting manifestations. A potassium level of 6.1 mEq/L is elevated and should be seen first. The client with a calcium of 10.0 mg/dL, the client with a sodium level of 136 mEq/mL, and magnesium level of 2.0 mEq/L are within the normal range.

The nurse is developing the plan of care with a client who is postoperative right hip replacement. The client has identified several goals. Which goal should the nurse identify as short-term? The client will have pain control at an acceptable level. The client will be able to bear weight on the right leg. The client will walk independently to the bathroom. The client will understand incision care before discharge.

The client will have pain control at an acceptable level. Rationale: Client goals are identified as long-or short-term outcomes, focusing on when the client will achieve the goal. A short-term goal focus on client outcomes that focus on the immediate needs of the client, such as pain control. Long-term goals require a longer time to achieve the client outcomes, such as discharge instructions or return of function.

The nurse is reviewing the discharge plans for assigned clients. Which client should the nurse request a prescription for skilled nursing home care? The client who has cancer and is weak from chemotherapy. The client with an infection and requires IV antibiotics. The client who had knee surgery and is walking with crutches. The client with dementia and needs assistance with meals.

The client with an infection and requires IV antibiotics. Rationale: When reviewing discharge plans, the nurse should assess for the need of skilled home care to ensure a safe transition home. Skilled nursing home care is prescribed for clients who required specific, skilled professional care, such as requiring of enteral tube feeding, wound care, medication management, and blood therapies. The client with crutches and client who is weak do not require skilled nursing care at home. The client with dementia who needs assistance with meals does not require skilled nursing care.

The nurse is planning care for a group of assigned clients. Which clients are at the highest risk for impaired skin integrity? The client with cognitive impairment who has an indwelling urinary catheter The client who had a colonoscopy with a prescription for bedrest The client who had a knee replacement who requires assistance out of bed The client with bronchitis who is receiving prescribed oxygen via nasal cannula

The client with cognitive impairment who has an indwelling urinary catheter Rationale: Clients who are at highest risk for impaired skin integrity have underlining health issues that impair wound healing, have mobility issues, and take prescribed medication that can suppress wound healing. The client with cognitive impairment may not be able to reposition or verbalize the need to change positions. An indwelling urinary catheter increases moisture, which can cause skin impairment.

The nurse is assigned to care for four clients on a medical-surgical floor. After receiving report, which client should the nurse assess first? The client with chronic renal failure who just returned from dialysis. The client with asthma who is now ready for discharge. The client with peptic ulcer disease who has been vomiting all day. The client with pancreatitis who was admitted yesterday.

The client with peptic ulcer disease who has been vomiting all day. Rationale: A perforated peptic ulcer may result in nausea, vomiting and abdominal distention or board-like abdomen. This might be a life-threatening situation. The client should be assessed immediately for initial findings of shock with notification of the health care provider. The other clients would be considered stable with minimal risk of an emergency.

The nurse is reviewing the plan of care for assigned clients. Which client should the nurse identify as having the highest risk for endocarditis? The client with uncontrolled hypertension who has a peripheral IV The client with atherosclerosis who has a positive stress test The client with renal failure who has a non-tunneled dialysis catheter The client with lung cancer who has a prescription for oral opioid

The client with renal failure who has a non-tunneled dialysis catheter Rationale: Endocarditis is an infection of the endocardium layer of the heart and heart valves. The infectious organism enters the bloodstream which flows through the heart, infecting the valves or endothelial tissue. A client with invasive devices, such as a non-tunneled dialysis catheter that is placed in the subclavian, have a high risk for developing endocarditis. Other risk factors include clients with congenital heart defects, cardiomyopathy, prior valve disease, or IV drug use.

The nurse has just received change of shift report for four clients in an acute rehabilitation facility. Based on this report, the nurse should assess which client first? The client with arthritis who reports moderate pain The client with insomnia who reports daytime fatigue The client with a surgical dressing who reports clear drainage The client with unilateral leg swelling who reports shortness of breath

The client with unilateral leg swelling who reports shortness of breath Rationale: The client who reports anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Increased daytime fatigue may be a symptom of insomnia. After surgery, an incisional dressing may drain serous or sanguineous fluid. Careful assessment of the dressing should be monitored. The client with arthritis may report mild to severe pain based on the type of arthritis they are experiencing. Insomnia, arthritis, and a surgical dressing site with drainage aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism

The client with acute coronary syndrome (ACS) is transferred from the emergency department (ED) to a telemetry unit three days ago. Which action by the nurse would breach client confidentiality? The emergency department (ED) nurse gave a verbal report to the nurse on the telemetry unit before transferring the client to that unit. The telemetry nurse notified the on-call provider about a change in the client's condition. The emergency department (ED) nurse reviewed the client's latest laboratory results. The telemetry nurse updates the client's spouse on their condition with the client's permission.

The emergency department (ED) nurse reviewed the client's latest laboratory results. Rationale: The ED nurse is no longer directly involved with the client's care and has no legal right to information about the client's present condition or latest laboratory results. Anyone directly involved in their care, such as the telemetry nurse and the on-call provider, has the right to information about the client's condition. Because this client asked the nurse to update their spouse, doing so doesn't breach confidentiality. The ED nurse can give a verbal report to the telemetry nurse prior to transfer to that unit, as this is not a breach of confidentiality.

A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include which approach? Increased numbers of older adults and of the chronically ill of all ages A steep rise in provider fees and in insurance premiums The escalation of fees with a decreased reimbursement percentage High costs of diagnostic and end-of-life treatment procedures

The escalation of fees with a decreased reimbursement percentage Rationale: The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee-for-service. Reimbursement for Medicare and Medicaid recipients based on fee-for-service also escalates health care costs.

A postoperative client with a hip fracture has been referred to a rehabilitation center for continuity of care. Which priority documentation will the nurse include with the referral? The latest physical therapy progress notes The surgical report A record of current pain management A copy of the last physical assessment

The latest physical therapy progress notes Rationale: The latest physical therapy progress notes provide information on the client's mobility and can help the rehabilitation center formulate a plan of care. The surgical report does not provide relevant information on the client's current progress. A record of current pain management provides information about the client's treatment; however, it does not provide relevant information regarding mobility. A copy of the last physical assessment provides information on the client's overall health status but is not specific to the diagnosis and client's rehabilitation needs.

The nurse is working in a health care setting that utilizes an electronic medical record (EMR) for documentation. Which actions will reduce the risk for inappropriate access to confidential client information? Select all that apply. The nurse writes down their current password on a list that's kept in the manager's office. The nurse changes their personal password for the EMR more frequently than required. The nurse reviews only the medical records of assigned clients during their shift. The nurse utilizes the automatic sign-off to close the medical record after a period of inactivity. The system administration department monitors all medical records accessed by staff members

The nurse changes their personal password for the EMR more frequently than required. The nurse reviews only the medical records of assigned clients during their shift. The system administration department monitors all medical records accessed by staff members Rationale: Practices that support EMR security include frequently changing passwords (using a combination of letters, numbers and symbols) and not sharing passwords with others. The information technology department typically monitors all access to an EMR and tracks unauthorized log-ins. The nurse should only review medical records for their assigned clients. Best practice is to sign or log off when leaving the computer screen and not rely on an automatic timeout because this can leave the system temporarily open for others to view/access confidential client information.

After a stressful shift at the hospital, the nurse writes the following post on their personal social media account: "Today was a rough day. One of my clients was in a terrible car crash and hemorrhaged. I felt so bad for the family." Which consequence could result from the nurse posting this information online? The nurse could be terminated from employment at the hospital for breach of client confidentiality. The information was posted without mention of personal identifiers, so legally no consequences can follow. The nurse could be reprimanded for not first clearing the post with the hospital's administration team. The nurse could be asked to post a disclaimer that they do not represent the hospital on this social media account.

The nurse could be terminated from employment at the hospital for breach of client confidentiality. Rationale: Many health care facilities have adopted a social media policy. It is important to understand that nurses can be terminated (i.e., fired) for posting personal information about clients online, because this is an invasion of privacy. In addition to being a Health Insurance Portability and Accountability Act (HIPAA) violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives state's attorneys the right to pursue violations of client privacy. Maintaining confidentiality is an important aspect of professional behavior. Sharing personal information or gossiping about others violates nursing ethical codes and practice standards.

The nurse is admitting a client with pneumonia to the medical-surgical unit. When would it be most appropriate for the nurse to initiate discharge planning for this client? When the client is informed of their date of discharge Upon admission to the hospital Immediately after the client's condition is stabilized When the client or family demonstrates readiness to learn

Upon admission to the hospital Rationale: With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to an emergency department or hospital unit. Thus, is the thought "discharge planning begins on admission."

The nurse is admitting a client with pneumonia to the medical-surgical unit. When would it be most appropriate for the nurse to initiate discharge planning for this client? When the client is informed of their date of discharge Upon admission to the hospital Immediately after the client's condition is stabilized When the client or family demonstrates readiness to learn

Upon admission to the hospital Rationale: With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to an emergency department or hospital unit. Thus, is the thought "discharge planning begins on admission."

Which nursing practice best reduces the chance of communication errors that could lead to negative client outcomes? Speak using a professional tone on the telephone Document nursing care at the end of the shift Maintain respectful working relationships with all staff Use standardized forms for client handoffs

Use standardized forms for client handoffs Rationale: Nurses should use standardized forms to improve communication between caregivers. A standardized form will decrease the risk of omitting pertinent information concerning the client's care. The options of maintaining a respectful working relationship and using a professional tone while speaking on the telephone are good practice, but not as vital as standardized forms. Documenting nursing care at the end of the shift is incorrect. Documentation should be done immediately following the provision of care. This will decrease the likelihood of omitting important information.

The nurse is administering medication to a client who does not speak English. Which of the following strategies should the nurse implement to ensure the client understands the purpose of the medication? Select all that apply. Use the translation phone line to interpret information between the client and nurse Communicate through a facility-approved interpreter Use correct medical terminology during instructions Maintain eye contact with the client even when speaking to an interpreter Plan to take a longer amount of time than usual for medication administration

Use the translation phone line to interpret information between the client and nurse Communicate through a facility-approved interpreter Maintain eye contact with the client even when speaking to an interpreter Plan to take a longer amount of time than usual for medication administration Rationale: There are several tools available for the nurse to help the client who does not speak English. These include translation phone lines and facility-approved interpreters. The nurse should maintain eye contact with the client throughout the communication and should be prepared for the encounter to take additional time. Medical terminology should be kept to a minimum during communication with clients in general but especially for clients with limited English proficiency.

The nurse is administering medication to a client who does not speak English. Which of the following strategies should the nurse implement to ensure the client understands the purpose of the medication? Select all that apply. Use the translation phone line to interpret information between the client and nurse. Communicate through a facility-approved interpreter. Use correct medical terminology during instructions. Maintain eye contact with the client, even when speaking to an interpreter Plan to take a longer amount of time than usual for medication administration.

Use the translation phone line to interpret information between the client and nurse. Communicate through a facility-approved interpreter. Maintain eye contact with the client, even when speaking to an interpreter Plan to take a longer amount of time than usual for medication administration. Rationale: There are several tools available for the nurse to help the client who does not speak English. These include translation phone lines and facility-approved interpreters. The nurse should maintain eye contact with the client throughout the communication and should be prepared for the encounter to take additional time. Medical terminology should be kept to a minimum during communication with clients in general, but especially for clients with limited English proficiency.

The nurse is caring for a client receiving treatment for methicillin resistant staphylococcus aureus (MRSA). Which of the following findings should be reported to the pharmacist? Vancomycin trough level 22 mg/L Creatinine Clearance 80 ml/min White Blood Cell Count 10,000 Serum osmolality 290 mOsm/kg

Vancomycin trough level 22 mg/L Rationale: The pharmacist plays a role in determining the appropriate amount of drug administered, especially in cases where the drug may cause toxicity. Measurement of both peak and trough levels helps maintain therapeutic serum levels without excessive toxicity. A trough above 20 mg/L indicates that a dosage adjustment may be needed to reduce the risk of kidney injury. The remaining lab values are within expected ranges and do not need to be reported.

The nurse is evaluating the completion of a client's wound dressing that was delegated to a licensed practical nurse (LPN). Which nursing action is appropriate? Obtain report from the LPN. Ask the client if the dressing was done. Check the medical record. Visualize the new dressing.

Visualize the new dressing. Rationale: To evaluate the completion of a dressing change that was delegated, the nurse should look at the dressing to ensure that it is clean and appropriately placed. Obtaining a report from the LPN is important for continuity of care, but does not evaluate completion of the dressing. Checking the medical record is important to ensure documentation has been completed but does not evaluate the actual task. Asking the client if the dressing was done does not evaluate the completion of the task.

The nurse is providing a transfer report for a client. Which of the following is the priority for the nurse to include in the report? When the next dose of prescribed medications is scheduled What allergies the client has Whether the client will be discharged to a skilled nursing facility The last set of vital signs

What allergies the client has Rationale: When completing the transfer report, the nurse should provide information about the client that is relevant to the client's safety. The nurse should report the name, age, admitting diagnosis, and allergies. While the next dose of prescribed medication, the last set of vital signs, and discharge plans are important, it is information that can be retrieved from the medical record and is not imperative to client safety.

The nurse knows that a client's information should be kept confidential. In which of these situations shall the nurse make an exception to this practice? When a visitor insists that they have been given permission by the client When the client threatens to harm themself or another individual When the healthcare provider (HCP) decides the family has a right to know When the client's family member offers information about the client

When the client threatens to harm themself or another individual Rationale: Client information is kept private unless the client states verbally or in writing that their information can be shared with another individual. In addition, if the client becomes incapacitated and they have a next of kin or health care proxy, their information can be shared with one of these individuals. The only exception to this rule is if the client threatens to harm themself or another individual. The Tarasoff ruling or duty to warn, instructs health care workers that if a client threatens to harm themself or another individual, they must warn the intended victim and contact the police.

The nurse is assisting a client who is on strict bedrest off a bedpan. The nurse notes the client's skin on the coccyx is reddened and non-blanchable. The nurse should collaborate with which member of the healthcare team for this client? Wound care nurse Registered dietician Physical therapist Charge nurse

Wound care nurse Rationale: A certified wound care nurse is a nurse that has become certified in treating wounds (CWCN), continence care (CCCN), ostomies (COCN), or all three, making them a fully certified wound ostomy and continence nurse (CWOCN). They receive consultations for treatment and monitoring of wounds/ostomies, provide direct care, educate patients, families, and nurses, and manage wound care programs. The primary nurse should collaborate with the wound care nurse to develop a plan of care that is evidence-based and in accordance with facility protocol.

The nurse is admitting an older adult client with diabetes who has a suspected blood stream infection. The client lives alone, and an unstageable sacral wound was identified during the assessment. Which of the following referrals is the priority? Wound care nurse Social worker Physical therapist Diabetes educator

Wound care nurse Rationale: Wound care nurses are registered nurses who hold a baccalaureate degree or higher and have completed additional education focused on wounds, ostomies, and/or continence care. This nurse can assist by assessing the wound and helping the healthcare team devise appropriate interventions. The social worker helps clients with social, emotional, and environmental factors that affect their well-being. This client is still quite ill so this is not the priority. Physical therapy and diabetes education are not the priority because the client is likely acutely ill and cannot participate in rehabilitation or education.

A nurse is providing care to a client with a complex abdominal wound. The client tells the nurse, "My healthcare provider told me I was going to be discharged soon, but I don't think I can afford all of my wound supplies." How does the nurse respond to the client's concern? Your social worker will be informed of your needs prior to discharge." "A list of wound care supply stores will be given to you at discharge." "Is there anyone in your family who can help you purchase wound supplies?" "How will you be obtaining the medications necessary for your wound care?"

Your social worker will be informed of your needs prior to discharge." Rationale: Social workers can assist clients with finding financial resources for their medical care. The nurse refers the case to the client's social worker prior to discharge. Providing the client with a list of wound care supply stores does not address the client's financial difficulties. The nurse should refer the client to a social worker prior to suggesting the purchase of wound care supplies by the family. Asking the client how they will be obtaining their medications does not address the client's financial concerns.

The nurse is assessing a new staff member's competency before delegating tasks to them. Which action by the nurse is most appropriate? Request that the staff member to share their educational background. Ask the staff member if they are able to complete the task independently. Observe the staff member complete a task for the first time. Assess the staff member's level of experience.

Observe the staff member complete a task for the first time. Rationale: To ensure that a new staff member is competent with a skill, the nurse should observe that staff member perform that task for the first time. Gathering data about the staff member's education and experience or confidence in completing the task might be helpful, but does not directly evaluate competence.

The nurse is caring for a client who states that they would like to leave against medical advice. Which statement by the nurse is appropriate? "You have the right to leave but you will need to sign a form stating that you know the risks." "You cannot leave until you have completed your treatment plan." "If you don't want to help yourself the hospital cannot help you." "If you leave before you have a discharge order I will have to notify law enforcement."

"You have the right to leave but you will need to sign a form stating that you know the risks." Rationale: Clients have the right to refuse treatment and leave a facility if they choose. It is important that the nurse explains to the client the risks of leaving against medical advice but if the client still wants to leave after this education, they will sign a form that states they understand the education presented. Unless the client cannot make decisions for themselves, medical staff cannot force a client to stay. The other statements are not appropriate for the nurse to make.

The nurse is preparing to assign tasks to various staff members. Which task would be appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? Assisting a client with ambulation Inserting a straight urinary catheter Assessing a client's oxygenation status Documenting an admission assessment

Assisting a client with ambulation Rationale: The UAP can assist a client with ambulation regardless of their level of experience. UAPs cannot perform or document assessments and they cannot complete invasive procedures, such as catheter insertions.

The nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource? The American Nurses Association's Social Policy Statement With a nurse colleague who has worked in that state two years ago The state nurse practice act in which the assignment is made The policies and procedures of the assigned agency in that state

The state nurse practice act in which the assignment is made Rationale: The state Nursing Practice Act is the governing document of the scope of practice in any given state. The assigned agency policy would not govern what the Registered Nurse can do in a state and while a nursing colleague may be knowledgeable, the nurse should review the primary legal document to ensure understanding. The American Nurses Association's Social Policy Statement provides information on the profession of nursing through the Social Contract theory.

The nurse is caring for a client who will be undergoing an elective surgery in 1 week. The client speaks English as a second language. What action is the priority? Obtain an informed consent form in the client's spoken language Schedule a chest radiograph Complete an electrocardiogram Have the interpreter ask the client if they have an advance directive

Obtain an informed consent form in the client's spoken language Rationale: Clients who do not speak English should be presented with a consent document written in a language understandable to them and have an interpreter to aid in the consent process.

While walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which statement made by the UAP would require the nurse to intervene? "Since I am late for lunch, would you perform my client's blood glucose test?" "If we work together, we can get all of the client care completed." "This client seems confused; we need to watch the client closely." "I'll come back and make the bed after I go to the lab."

"Since I am late for lunch, would you perform my client's blood glucose test?" Rationale: Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs) can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses are accountable for all nursing care; if UAPs cannot complete assignments, they should notify the nurse, who will reassign the task.

The nurse is caring for a client who has been diagnosed with an advanced stage of cancer. The client asks the nurse "Do I have to go through treatment." Which response by the nurse is appropriate? "You should consider treatment to spend more time with your family." "You have the right to choose how you want to proceed." "I need to fulfill the provider's orders regardless." "This cancer can cause serious pain."

"You have the right to choose how you want to proceed." Rationale: Clients have the right to refuse treatments and procedures for any reason; therefore telling the client that they have choices is an appropriate response. All other responses do not respect this right. Forcing or coercing the client into a plan of care that they do not agree with is a legal issue.

The nurse is approached by a healthcare provider for an update on a client transferred to another unit. Which statement would be most appropriate for the nurse to make? "The client was fine when I transferred them". "You will have to check with the nurse that is assigned to that client. " "I can show you the latest lab results if you want." "I can update you in a more private area.

"You will have to check with the nurse that is assigned to that client." Rationale: The nurse is ethically and legally obligated to protect clients' privacy and maintain the confidentiality of their medical information. It is appropriate to direct questions about the client to the currently assigned nurse who will be able to update the healthcare provider appropriately and provide lab results if necessary. Since the client was transferred to another unit, the nurse being questioned for an update neither has the right nor accurate information to provide to the healthcare provider. Although it is best to make the conversation private, it is a breach of confidentiality to share information about a client no longer in direct care.

The nurse is supervising the care of an older adult client who is receiving assistance with personnel hygiene from unlicensed assistive personnel (UAP). Which action by the UAP requires intervention? Testing the temperature of the water in the bath basin Exposing only the part of the client being cleansed Applying a generous amount of soap directly to the washcloth Drying the skin thoroughly including between the toes

Applying a generous amount of soap directly to the washcloth Rationale: Although unlicensed assistive personnel (UAP) are increasingly performing hygiene measures, the nurse is responsible for ensuring that hygiene measures are performed satisfactorily. Soap cleans the skin, but at the same time that it removes dirt from the surface, it affects the lipids that are present on the skin and the skin pH. This contributes to drier skin, damaging the barrier function of the skin. All other interventions are appropriate.

The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study about staff attitudes toward client care. All staff are invited to participate in the study, if they wish. This type of research participation affirms which ethical principle? Justice Beneficence Anonymity Autonomy

Autonomy Rationale: The principle of autonomy means individuals must be free to make independent decisions about participation in research without coercion from others. Anonymity means the person's identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act. Justice relates to fairness.

The nurse is caring for a client who has been nothing by mouth (NPO) for a test and is now prescribed a diet. Which action by the nurse is appropriate? Call the dietary department to ensure that the client gets a correct tray. Notify the dietitian that the diet has been changed. Enter the order into the electronic health record for the healthcare provider. Wait until the next mealtime to begin feeding the client.

Call the dietary department to ensure that the client gets a correct tray. Rationale: Continuity is a process by which healthcare providers give appropriate, uninterrupted care. Continuity depends on excellent communication to prevent omissions in care. The nurse's priority is to ensure that the client gets appropriate care based on their physiological needs.

A nurse is performing a focused health history on a client scheduled for an urgent appendectomy. The client verbalizes being homeless and denies a social support system. Which action will the nurse perform? Refer the client to case management for a financial assistance application. Collaborate with social work to locate a temporary shelter for the client upon discharge. Encourage the client to call a family member before the procedure. Perform a full health history to identify the client's social needs.

Collaborate with social work to locate a temporary shelter for the client upon discharge. Rationale: The nurse should expect to collaborate with the unit social worker to locate temporary shelter for the client. The client may require medical care postoperatively and the nurse should ensure adequate shelter for the client before discharge. There are various reasons the client may be homeless aside from financial struggles. The nurse's priority is to ensure the client has shelter before discharge. The client has denied having a social support system. Encouraging the client to call a family member does not provide sensitive care. The client is scheduled for an urgent appendectomy. Performing a full health history is not appropriate at this time.

The nurse is caring for a client who has diabetes mellitus. Which of the following findings should be reported to the provider immediately? Low carbohydrate intake Nocturia Ambulation refusal by the client Confusion

Confusion Rationale: Any signs of hypoglycemia, such as new onset confusion, diaphoresis, dizziness, or low capillary glucose levels, should be reported to the provider. The client's intake and activity level is important but does not need to be reported to the provider. Nocturia is an abnormal finding but is not a cause for concern.

During the admission process, the staff nurse realizes that the information on the identification (ID) bracelet does not match the information on the client's admission face sheet. What action should the nurse take? Communicate with staff that the patient must be identified using the admission face sheet only Contact the admissions department to create a new ID bracelet Use a permanent marker to change the incorrect information on the ID bracelet Write the corrected information on the whiteboard in the client's room

Contact the admissions department to create a new ID bracelet Rationale: The admissions department has the responsibility to verify the client's identity, apply the correct bracelet or another identifier to the client, and keep all records in the system accurate and consistent. The other options are unsafe practices that could lead to error and patient harm.

The nurse is reviewing the discharge plan for a client who had a laparoscopic cholecystectomy and was newly diagnosed with obstructive sleep apnea. The nurse should assess the client's need for which equipment? Continuous positive airway pressure (CPAP) device Sequential compression device (SCD) Home oxygen therapy Wound care dressing supplies

Continuous positive airway pressure (CPAP) device Rationale: Continuous positive airway pressure (CPAP) is used to prevent airway collapse in clients with OSA. The use of sequential compression devices (SCDs) are used to improve blood flow in the legs as a method of deep vein thrombosis (DVT) prevention, not OSA. Administration of home oxygen therapy at night may help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea. Wound care dressing supplies are appropriate for a client with an open wound or surgical incision. Laparoscopic procedures do not require wound dressings.

The nurse is caring for a client who is refusing a treatment that has limited benefit. The family asks the nurse to try to convince the patient to begin the treatment. Which action by the nurse is consistent with ethical practice? Decline to convince the client to begin treatment Encourage the family to try to convince the client Inform the physician that the family would like the client to begin treatment Ask the client if they are sure of their decision

Decline to convince the client to begin treatment Rationale: The Code of Ethics for Nurses states that the nurse promotes, advocates for, and protects the rights of the client. This includes the right to make decisions that the nurse or family may not agree with. The nurse's primary commitment is to the patient, and they should not encourage others to persuade the client to change their mind.

A nurse uses the Nurse Practice Act to guide professional standards. What actions are within the legal scope of practice for the registered nurse? Formulating a medical diagnosis and treatment plan Prescribing alternative therapy for chronic pain Delegating wound care to a licensed practical nurse Consulting a dermatologist for skin care

Delegating wound care to a licensed practical nurse Rationale: The registered nurses' scope of practice includes delegating wound care to a licensed practical nurse. Registered nurses need a healthcare provider's order to consult a dermatologist, prescribe alternative therapy for chronic pain, or formulate a medical diagnosis and treatment plan.

The nurse is assessing a group of clients. Which client problem should be reported to the respiratory therapist? Sanguineous drainage on the nasal packing of a client who is 1 day post hypophysectomy Dry mucus membranes and sore throat of a client on continuous positive airway pressure (CPAP) Shortness of breath in the client diagnosed with heart failure Complaint of chest pain from a client who experienced a motor vehicle collision (MVC)

Dry mucus membranes and sore throat of a client on continuous positive airway pressure (CPAP) Rationale: Respiratory therapists are trained in techniques and equipment that improve oxygenation and pulmonary function, including CPAP. The client with the hypophysectomy is expected to have some drainage, but this may require intervention from the surgeon. The client with heart failure may require diuresis and may later require a respiratory thereapist, but not at this time. The client with chest pain from an MVC likely requires radiologic testing and pain management.

A nurse is providing care to a client with a traumatic brain injury. The client will require individualized financial assistance and long-term medical needs. The nurse will refer the client and their caregiver to which specialty resource? Life care planner Support group Rehabilitation center Counseling service

Life care planner Rationale: Life planners help clients coordinate their long-term needs within the community. Life care planners develop an individualized plan for each client based on their needs and assist with finding necessary resources. Support groups help clients and caregivers cope with a diagnosis, but do not offer specialized care. Rehabilitation centers offer long-term physical therapy but do not assist with financial concerns. A counseling service provides mental and emotional assistance. However, this service does not provide for physical and financial needs.

A nurse is reviewing care plans for several clients in the geriatric unit. Which intervention on a client's care plan will the nurse revise? Keep a client with diverticulitis on NPO status. Continue fall risk precautions for a client with dementia. Maintain bedrest for a client who is malnourished. Implement aspiration precautions for a client with a stroke.

Maintain bedrest for a client who is malnourished. Rationale: The nurse should revise the intervention of bedrest for a client who is malnourished. The client is at risk for skin integrity issues and requires frequent position changes or ambulation. An NPO status for a client with diverticulitis is expected and does not need to be revised. A client with dementia is at risk for falls due to disorientation and decreased coordination. This intervention does not need revision. A client with a stroke can have dysphagia, increasing the risk of aspiration. Aspiration precautions maintain client safety.

Which of these activities can the nurse assign to an unlicensed assistive person (UAP)? Care for a stable client. Reinforce teaching to the client. Provide basic care to the client. Create a plan of care for the client.

Provide basic care to the client. Rationale: UAPs' limited scope includes (but may not be limited to) assisting with ADLs such as bathing, feeding, toileting, obtaining vital signs, input and output (I/O), performing point of care (POC) tests, such as a blood sugar check or 12-lead electrocardiogram, and recording height and weight. UAPs cannot reinforce teaching, create a plan of care or assume nursing care for a client - even if the client is stable.

The nurse is admitting a client from the postoperative care unit following an appendectomy. Which of the following is the priority for the nurse to assess? Surgical dressing Pulses Respiratory rate Pain

Respiratory rate Rationale: Frequent and skilled assessment of the client's airway, respiratory function, cardiovascular function, and the ability to respond to commands. The nurse should immediately assess the client's airway upon arrival to the PACU. Assessment of the surgical site, pulses, and pain should all be completed after the airway is deemed stable.

The client arrives to the unit in active labor and is accompanied by a minor child. The client does not speak English, but the child does. Another nurse can understand and speak the client's dominant language and is willing to serve as an interpreter. Which action will the nurse perform first? Call the other nurse to serve as an interpreter. Ask the client's child to translate until the interpreter arrives. Review facility policy on use of staff as interpreters. Use hand gestures to communicate until the interpreter arrives.

Review facility policy on use of staff as interpreters. Rationale: The nurse's first action would be to review facility policy on use of staff as interpreters. Providing culturally competent care is important and includes attempting to overcome language barriers; however, facility policy and legal considerations should be made first. It is not acceptable to have a child be responsible for translating pertinent medical information. Based on facility protocol, another nurse may be called to serve and assist as an interpreter. Using hand gestures to communicate may be an effective intervention, but not the first action the nurse should perform.

A nurse is planning for her new role as the nurse manager of a 30-bed inpatient medical unit in a busy acute care hospital. Which strategy should the nurse use to help with time management? Limit direct care of clients to 2 to 3 hours per day Set daily, prioritized goals of management tasks Plan to work a few extra hours on weekends Delegate tasks and skip unimportant meetings

Set daily, prioritized goals of management tasks Rationale: Time management strategies include setting goals and prioritization of not only management tasks but issues that arise on a daily basis on the unit. This is similar to time management of direct care for clients where the nurse prioritizes which clients to see first or which tasks to perform first. Still providing direct care would be a poor use of the manager's time. Direct client care should be done by a nurse manager only in extreme circumstances. The nurse manager will be expected to attend all required meetings and working "extra hours" does not help with managing time and completing management tasks within the expected work week.

The nurse is preparing to discharge a client home. A family member reports that the client's home has multiple safety hazards. Which member of the multidisciplinary team should be notified? Social worker Case manager Visiting nurse Healthcare provider

Social worker Rationale: Social workers assist patients and families in dealing with the social, emotional, and environmental factors that affect their well-being. They make referrals to appropriate community resources and provide assistance with securing equipment and supplies, as well as with health care finances. Case managers are closely involved with discharge plans, length-of-stay issues, and insurance constraints. Visiting nurses provide case management and direct care in the home setting. The healthcare provider would not have a role in this situation.

An experienced nurse manager is explaining a reward-feedback system to a new manager. Which statement best describes the characteristic of an effective reward-feedback system? Specific feedback is given as close to the event as possible. Staff are given feedback in equal amounts over time. Performance goals should be higher than what is attainable. Positive statements should precede a negative statement.

Specific feedback is given as close to the event as possible. Rationale: Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.

The nurse manager has initiated a fall risk assessment tool that increases staff and client interaction to promote increased safety. Which result indicates that the proposed initiative needs improvement? Improved client satisfaction scores Decreased volume of unit-based falls Adoption of the fall risk assessment tool on a hospital-wide basis Staff reporting the time requirement of the new tool

Staff reporting the time requirement of the new tool Rationale: When implementing a new practice protocol, evaluation of the end users of the protocol is important for compliance. The staff reported a time requirement of the new tool should indicate that the proposed initiative needs improvement. If staff feel that the tool takes too much time, it won't be used which may negate the goal to decrease falls and increase client safety. If the volume of client falls decreases, client satisfaction scores increase, and the fall risk assessment tool is adopted on a hospital-wide basis, then the initiative does not need improvement.

The interdisciplinary team is meeting to discuss the discharge plan for a client following total hip replacement surgery. Which assessment finding is most important for the team to address? The adult daughter will be responsible for shopping and driving the client after discharge The client does not like the taste of the oral potassium supplement medication. The partner expresses some discomfort with the dressing change. The home is a two-story and all bedrooms and bathrooms are located upstairs.

The home is a two-story and all bedrooms and bathrooms are located upstairs. Rationale: Nurses are charged with the responsibility to advocate for clients. Because of the intimate work with clients, nurses often discover critical information that will impact discharge planning. It is important to share these insights with the health care team to ensure the client's needs are met after discharge. A client who has undergone major orthopedic surgery can expect some mobility impairment after discharge. The nurse should ask questions regarding the physical characteristics of the home including stairs, location of essential rooms, bathroom set up, pets and carpeting. Therefore, it is most important to identify and address any potential safety issues in the client's home.

The nurse is caring for a client who is being treated for complications of a chronic disease on a medical-surgical unit. The nurse understands that which people can have access to the client's medical record? Select all that apply. The client's spouse or another close family member The person who has health care power of attorney The facility researcher collecting data for a study to which the client consented The emergency department nurse who originally admitted the client and now wants to know the client's current status The nursing instructor planning clinical assignments The certified nursing assistant documenting vital signs

The person who has health care power of attorney The facility researcher collecting data for a study to which the client consented The nursing instructor planning clinical assignments The certified nursing assistant documenting vital signs Rationale: Safeguarding client privacy requires strict adherence to the ethical standards of confidentiality and need-to-know access. Only those individuals who are directly involved in the client's care should have access to his or her information. The ED nurse is no longer directly involved in the client's care and should not have access to information about the client. Without valid authorization, such as health care power of attorney, a spouse or other family members cannot access the client's medical records.

The nurse is planning care for a client who is postoperative from an intermaxillary fixation for a mandibula fracture. Which of the following should be the priority of the nurse place at the client's bedside? Nasogastric tube Wire cutters Syringes depressor

Wire cutters Rationale: The client who is postoperative intermaxillary fixation will have wires to keep the jawbone aligned. If a client experiences respiratory distress, the nurse will need to cut the wires to access the airway. A nasogastric tube is used to decompress the stomach, syringes are used to irrigate the mouth, and . depressor retracts the cheeks, but these are not a priority.

The nurse is preparing the discharge for a client who is postoperative total right knee replacement and has a prescription for home health care. To help ensure continuity of care, the nurse should confirm which information with the client? Address and phone number Insurance information Follow up appointment with HCP Ability to change dressing

Address and phone number Rationale: Coordination of care is the responsibility of the interdisciplinary team. Patient care coordination should be seamless and accurate and should start at admission. To avoid a lapse in care and maintain client safety, the nurse should verify the client's address and phone number prior to discharge to avoid a lapse in care. The insurance information is not pertinent information at this point in the process and should be discussed with a different department. The follow-up with the HCP can be coordinated at home with the home health nurse, client, and family. The dressing change can be done by the nurse and can be taught to the family by the nurse if needed.

The nurse is caring for a client who has bilateral soft wrist restraints in place. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? Assist the client with activities of daily living Monitor the client's physical safety Document the client's mental status Evaluate the need for continued use of restraints

Assist the client with activities of daily living Rationale: The UAP can only be delegated tasks within their scope of practice, thus they should be able to assist with activities of daily living (ADLs). The nurse is responsible for documenting the client's status every hour, as well as their mental status. The nurse is also responsible for monitoring the client's physical safety.

The nurse is coordinating care for a postpartum client and her newborn with the unlicensed assistive personnel (UAP). The mother is positive for human immunodeficiency virus (HIV). The nurse should intervene if the UAP is observed doing which action? Assists the mother with breastfeeding positions Wearing gloves while changing the newborn's soiled diaper Places the infant on his or her back in the bassinet Assists the mother with ambulation to the bathroom

Assists the mother with breastfeeding positions Rationale: Current research recommends that a mother who is HIV positive or has AIDS is advised against breastfeeding because the virus can be transmitted through breast milk to the infant. Therefore, the nurse should intervene when observing the UAP assisting the mother with breastfeeding. It is correct to place an infant on his or her back to prevent sudden infant death syndrome. Standard precautions should be followed when caring for any client; health care providers should wear gloves when they anticipate contact with body secretions (changing a soiled diaper).

A client's family member calls for an update on the client's condition. What should the nurse do first before providing information to the caller? Check with the client and obtain permission to provide the caller with the requested information. Ask the family member who is currently visiting the client if it is okay to release the information. Call the physician to verify the client's condition before updating the caller. Decline the caller's request and notify the nurse supervisor of a potential HIPAA violation.

Check with the client and obtain permission to provide the caller with the requested information. Rationale: The nurse must have permission from the client to release information to the caller. If the client is unable to give permission and has a power of attorney for health care (POAH), then information shall only be given to the POAH. Family members can obtain updates from that person. Remember, it is difficult to know who is calling over the phone. The nurse should also be familiar with the organization's policy on requests for information over the phone.

A health care system utilizes decentralized scheduling on all the nursing units. What is the primary advantage of this management strategy? Allows requests for special privileges Considers client and staff needs Conserves time spent on planning Frees the nurse manager to handle other priorities

Considers client and staff needs Rationale: Decentralized scheduling takes into consideration specific unit, client, and staff needs. Staffing is decided based on priorities at the unit (micro) level, not the health care system (macro) level.

The nurse continually avoids answering the call light of clients with alternative lifestyles. The nurse's behavior is an example of which concept? Benevolence Stereotyping Discrimination Nonmaleficence

Discrimination Rationale: Nurses are responsible for caring for individuals in a manner that demonstrates benevolence and nonmaleficence. This nurse is discriminating against these clients by continually not answering the call light. Stereotyping is defined as the thought that all members of an ethnic group, culture, or race all act alike.

The surgical nurse is caring for a client following a cholecystectomy. Which task would be appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Assess the return of bowel sounds or passing flatus Document amount of output in the surgical drainage collection device Record amount of drainage on the surgical dressing Palpate for abdominal distention

Document amount of output in the surgical drainage collection device Rationale: The emptying, measuring, and recording drainage from a postoperative drain may be delegated to the UAP who has demonstrated competence in performing this task. While the nurse is responsible for all care-related decisions, the UAP can typically perform tasks that have predictable outcomes. The other tasks or activities require nursing knowledge, skill, or judgment and cannot be assigned to the UAP.

The nurse is currently evaluating COPD readmission rates in the Emergency Department. After identifying that most of the clients do not read discharge instructions, the nurse suggests which next step? Collaborating with the pharmacy for discharge medication Making follow up appointments for clients prior to discharge Educating the staff on the importance of updating language preferences Translating discharge instructions into multiple languages

Educating the staff on the importance of updating language preferences Rationale: Proper discharge planning should begin on admission. Avoiding reactionary discharge planning is one way to improve the effectiveness of discharge planning. Educating the staff to update language preferences on admission would identify any language barriers. Educating the client in the native language helps to decrease miscommunication. The discharge instructions should be given in the client's preferred language as well as medication labels from the pharmacy, if possible. Making follow up appointments for clients may prove to be difficult due to social issues, such as transportation.

The nurse manager uses a block scheduling plan for staffing. Staff members have asked for many changes and exceptions to the schedule over the past few months, and the nurse manager is considering self-scheduling. Which type of effect does the nurse manager anticipate with self-scheduling? Improved team morale Reduced overtime payouts Improved quality of care Decreased staff turnover

Improved team morale Rationale: Nurses in direct care positions are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator rather than the decision-maker of the schedule for unit needs when self-scheduling exists. Peer pressure and teamwork are the driving forces during self-schedule approaches.

The nurse has just received a prescription to discharge a client home who has limited mobility. Which of the following actions would be most appropriate? Ask the client if they have family to take care of them Delay discharging the client until the client can ambulate independently Include the unit social worker in discharge planning Tell the client that they need to remove fall hazards from their home

Include the unit social worker in discharge planning Rationale: The most appropriate action would be to include a social worker or case manager in the client's discharge planning. This person can connect the client with resources that may be needed for safe discharge. Asking the client about their support system and education about a safe environment may be necessary but are not the most important action. Clients who cannot ambulate independently can be discharged but will need support, such as assistive devices, education, and other resources.

While caring for a client after lumbar spine surgery, which action can the nurse on the ortho-spine unit delegate to the unlicensed assistive person (UAP)? Log roll the client from side to side every two hours. Check the client's ability to plantar and dorsiflex the foot. Determine the client's readiness to ambulate. Ask about pain control with the patient-controlled analgesia (PCA).

Log roll the client from side to side every two hours. Rationale: Repositioning a client is included in the training of UAPs. UAPs working on a specialty unit, such as ortho-spine, will be familiar with how to maintain alignment for a postoperative spinal surgery client. Evaluating the effectiveness of pain management, assessing neurologic function such as plantar and dorsiflexion and evaluating a client's readiness to ambulate after surgery require higher level nursing education and scope of practice and, therefore, cannot be delegated to UAPs.

The nurse is caring for a client who is scheduled to have a surgical procedure. The client states that they don't know if they want to have the surgery. Which action by the nurse is appropriate at this time? Notify the surgeon of the client's concerns. Reassure the client that they need the procedure. Ask the client to sign an informed consent. Tell the client that the OR nurse will discuss their concerns.

Notify the surgeon of the client's concerns. Rationale: If a client states that they are unsure if they want to go through with a surgical procedure, the nurse should notify the provider of the client's wishes. The surgeon is responsible for discussing treatment options, risks, and benefits with the client. The nurse can educate the client, but should not push a client to have a procedure that they do not want to have. Putting off the client's concerns and stating that someone else will address them is not appropriate.

The nurse is collecting information to evaluate unit outcomes. Which of the following sources could the nurse use to gather data about client satisfaction? Post-discharge surveys Staff interviews Hospital infection statistics Length of hospitalization

Post-discharge surveys Rationale: To gather data about client satisfaction, the nurse would need to use sources in which the clients have answered questions or shared their opinions about the care they received. Post-discharge surveys are a possible source of this data. Staff interviews and other statistical data may provide insight about other management outcomes but do not address client satisfaction.

The nurse expresses concerns to colleagues regarding their nurse manager. The nurse states that the manager makes all the decisions and rarely seeks input from staff. What is the best description of the nurse manager's management style? Autocratic leadership Transformational leadership Participative leadership Laissez-faire leadership

Rationale: The manager's leadership style is that of autocratic. Autocratic leadership is a management style where one person controls all decisions and rarely seeks input from others. Leaders who follow this style make choices based on their own beliefs and do not involve others nor seek suggestions or advice. Transformational leadership aims to improve employee morale and promoting inclusion by creating a vision for their employees and communicating often. Laissez-Faire leadership allows employees to choose their actions freely and does not provide sufficient supervision. Participative leadership encourages employees to participate in decision-making but then makes the final decision for the group based on suggestions and feedback.

The nurse observes a social media post by a staff nurse that discusses the care of a client. Which of the following actions should the nurse take? Request the post be deleted Inform the client about the post Report the post to a supervisor Notify the board of nursing

Report the post to a supervisor Rationale: Social media are web-based technologies that allow users to create, share, and participate in virtual communities. These social media networks provide nurses the opportunity to share ideas, develop professional connections, and access education. There are policies in place to prevent sharing of client information. Disclosing information or posting defamatory remarks could lead to serious consequences. The nurse should report the post to a supervisor. Requesting the post to be deleted does not address the issue.

A nurse is providing care to an older adult client with newly diagnosed cancer. The client's family tells the nurse, "We aren't sure about pursuing treatment; no one in the family has the resources to care for our loved one at home." Which action does the nurse perform? Contacts the healthcare provider to inform them of the family's decision Refers the case to the ethics committee for review Calls the nurse supervisor to report refusal of care Requests a consult to case management for care coordination

Requests a consult to case management for care coordination Rationale: Case managers can assist the client and their family with resources for treatment and post-discharge arrangements. The nurse requests a consult with case management to assist the client's family with the client's care. Contacting the healthcare provider regarding the family's decision does not advocate for the client. An ethics committee and notifying the nurse supervisor are not indicated at this time. The nurse must first refer the client's family to a care coordinator for assistance.

The nurse overhears nursing students talking on the elevator and describing a client who was admitted to the unit. One of the nursing students starts to disclose the client's medical information. What is the first action by the nurse? Stop the conversation in the elevator Contact the nursing students' instructor Report the incident to the nurse manager Inform the client about the privacy violation

Stop the conversation in the elevator Rationale: The nursing students are violating HIPAA and confidentiality requirements, and the nurse should act immediately to stop the conversation. The nurse may contact the nursing students' instructor and report the behavior and report the incident to the nurse manager, but these are not the first actions the nurse should make if overhearing this conversation on an elevator. The nurse should not tell the client about the breach of confidentiality.

During a discussion with the nurse manager, a staff nurse confides that she is attracted to a client regularly assigned to her. Which of the following actions should be implemented following this discussion? The nurse waits until after discharge to tell the client about her feelings The nurse reassigns all personal care of the client to the nursing assistant The nurse continues to provide care for the client The nurse transfers the care of the client to another nurse

The nurse transfers the care of the client to another nurse Rationale: Nurses must practice in a manner consistent with professional standards and be knowledgeable about professional boundaries. A nurse's challenge is to be aware of feelings and to always act in the best interest of the client, avoiding inappropriate involvement. In this case, the nurse did all the right things—aware of her feelings, she consulted with her supervisor and together they decided it would be best if this client were no longer assigned to this nurse. If the nurse had acted on her feelings, this would have been a boundary violation and she could have been subject to board of nursing disciplinary action.

The nurse has just successfully inserted a client's indwelling urinary catheter. Which of the following statements by the nurse is appropriate when discussing this update with the unlicensed assistive personnel? "Assess the client's skin around the catheter each day." "Document each time you perform perineal care." "Flush the catheter if the urine output decreases." "Discontinue the catheter when the client feels the need to void."

"Document each time you perform perineal care." Rationale: The unlicensed assistive personnel (UAP) can perform perineal care and should document each time that they perform this task. UAPs cannot assess the client or perform tasks such as flushing or discontinuing indwelling urinary catheters. They should be instructed to report things like urine output and client concerns to the nurse.

The nurse is conducting a telehealth visit for a client in their home. During the assessment, the client's neighbor joins the conversation and asks, "What's wrong with my friend? Should I take her to the hospital now?" What is the most appropriate response by the nurse? "Your neighbor is fine, don't worry." "I cannot tell you about their condition." "You should ask their spouse about their condition." "Here is my contact information for any questions you may have."

"I cannot tell you about their condition." Rationale: The nurse must remember that the client has a right to confidentiality, and information should only be shared with the client's consent. The nurse should tell the neighbor that the nurse cannot say anything about the client's condition. Asking the neighbor to call the nurse for information or to ask the client's spouse are not the correct responses as they do not maintain HIPAA protocol or the client's right to confidentiality and privacy.

The home health nurse is conducting a home visit with a client who has terminal heart failure and their partner who is the primary caregiver. Which statement by the partner would require the nurse to evaluate the plan of care? "I take a walk around the block twice a day." "I forgot when the last time I visited with friends." "I often order dinner to be delivered." "I find time to take a shower in the evenings."

"I forgot when the last time I visited with friends." Rationale: Clients who have chronic or terminal conditions often require family to become caregivers. When conducting a home visit, the nurse should also assess the coping skills of the client's primary caregiver to evaluate for caregiver burnout. A caregiver who has limited contact with people outside the house, does not take time to maintain their personal hygiene, does not take breaks from chores or find time to engage in activities are at risk for burnout.

The nurse is educating new staff on ethical practice. Which of the following statements by the staff indicates an understanding of professional boundaries? "Freely sharing my personal experiences with clients will increase rapport and trust." "I can share my experiences on social media as long as I do not use my client's names or personal information." "I should try to avoid caring for clients if there is a pre-existing outside relationship." "If the situation arose, I could date a former client without question."

"I should try to avoid caring for clients if there is a pre-existing outside relationship." Rationale: Every nurse-client relationship is viewed on the continuum of professional behavior from underinvolvement to overinvolvement, with the goal being a therapeutic relationship. Overinvolvement includes boundary crossings, boundary violations, and professional sexual misconduct. Oversharing is a form of boundary-crossing. The nurse should avoid situations where they have a previous personal, professional, or business relationship with the client. Post-termination relationships are complex because the patient may need additional services. It may be difficult to determine when the nurse-client relationship is completely terminated. Making a comment via social media, even if done on a nurse's own time and in their own home, regarding an incident or person in the scope of their employment, may be a breach of patient confidentiality or privacy as well as a boundary violation

The client admitted for an invasive procedure asks the nurse about informed consent. Which statement best describes the role of the nurse to ensure informed consent? "I will give a detailed description of the risks and benefits of the procedure." "I will give an explanation of each step of the procedure." "I will offer alternative options to this procedure." "I will ask questions to determine that you understand what you are signing."

"I will ask questions to determine that you understand what you are signing." Rationale: The nurse's responsibilities related to informed consent include ensuring the consent form is completed with signatures from the client, serving as a witness to the signature process, and determining whether the client understands what they are signing by asking pertinent questions. The healthcare provider is responsible for informing the client about the procedure and obtaining consent by providing a detailed description of the procedure or treatment, its potential risks and benefits, and alternative methods available.

The nurse is performing discharge teaching with an older adult client who was admitted with urosepsis. Which statement by the client would indicate the need for further teaching? "I will continue to take my prescribed antibiotics even if I feel better." "I will drink one glass of apple juice a day." "I will monitor my temperature for signs of a fever." "I will make sure that I void when I feel the urge."

"I will drink one glass of apple juice a day." Rationale: In teaching the client recovering from urosepsis, the nurse will provide further teaching to the client when stating the need to drink apple juice. For recurrent infection of the urinary tract, it is recommended that at least one glass of cranberry juice be added to the diet regimen per day. In addition, the use of ascorbic acid (vitamin C), 1000 mg daily, will help acidify the urine, promoting an environment where bacteria are less likely to grow. Other teaching recommendations include strict adherence to prescribed antibiotics, voiding every 2-3 hours to prevent overdistension, and reporting signs and symptoms of recurrent infection to the health care provider.

The nurse attended an education conference about ethics in nursing practice. Which statement by the nurse indicates an understanding of nonmaleficence? "In my nursing practice, I will follow protocols and policies to prevent harm to my clients." "When providing care, I will act fairly towards my client regardless of culture or race." "When I tell a client I will be back in an hour, I will make every effort to do so." "I will provide my clients with necessary information, so they can make decisions."

"In my nursing practice, I will follow protocols and policies to prevent harm to my clients." Rationale: Nonmaleficence is the ethical principle to do no harm. A nurse who demonstrates nonmaleficence will follow protocols and policies that are in place to prevent harm or injury to clients. Fidelity is the ethical principle of faithfulness, or keeping promises, such as returning to the client when stated. The nurse demonstrates autonomy for clients when providing the necessary information to make decisions. Beneficence refers to taking positive actions to help others.

The nurse is about to administer medication to a client when the client states, "I do not want to take that medication today." Which statement is the nurse's best response? "That's OK; it's all right to skip your medication now and then." "Is there any particular reason why you don't want to take your medicine?" "I will have to call your doctor and report this." "Do you understand the consequences of refusing your prescribed treatment?"

"Is there any particular reason why you don't want to take your medicine?" Rationale: When a new problem is identified, it is important for the nurse to collect accurate information directly from clients. This is crucial to ensure that clients' needs are adequately identified in order to select the best nursing care approaches. The nurse should pursue a conversation with the client to reveal any reasons for the medication refusal. It may be that the client has developed untoward side effects.

A healthcare provider informs the nurse that a client is hesitant about surgery despite an explanation of the procedure. Upon assessment, the client tells the nurse "I'm not sure I want surgery. I'm scared I won't wake up after." How does the nurse respond to the client? "It is normal to feel scared. Tell me why you feel you won't wake up." "You have nothing to worry about. The surgery will go well." "There are other options besides surgery. Let's contact your healthcare provider." "You have a right to refuse surgery. I will let your healthcare provider know."

"It is normal to feel scared. Tell me why you feel you won't wake up." Rationale: The nurse uses therapeutic communication to discuss treatment options with the client. The nurse should reassure the client their concerns are valid and explore the reason for their concern. Telling the client their surgery will go well is false reassurance. The nurse should encourage the client to voice their feelings about the current treatment before proposing an alternative or finalizing a refusal of treatment.

The nurse is discussing the planned daily care for assigned clients with the unlicensed assistive personnel. Which of the following statements by the nurse is appropriate? "Explain what to expect after the surgery to the client." "Put a nasal cannula on the client if the oxygen saturation is low." "Call the provider if the client has any trouble with eating." "Let me know what the client's blood pressure is."

"Let me know what the client's blood pressure is." Rationale: The nurse should instruct the unlicensed assistive personnel (UAP) to report collected data so that the nurse can determine if assessments or interventions are needed. The UAP should not be responsible for client education, placing oxygen delivery devices, or notifying the provider of abnormalities. All of those actions should be completed by the nurse.

The nurse is caring for a client with renal disease who has not started dialysis. When delegating tasks to the unlicensed assistive personnel, which statement is appropriate? "Provide oral care to the client every 2-3 hours." "Monitor the client for signs of fluid overload." "Tell the client that they cannot drink as much cola." "Inform the other UAPs that we will need to weight this client daily."

"Provide oral care to the client every 2-3 hours." Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Nursing care or tasks that should never be delegated except to another RN include initial and ongoing nursing assessment, determination of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated should be based on the training and competence of the individual accepting the delegation. Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.

A performance improvement (PI) nurse is auditing client records and notes a client's chart is missing documentation on advance directives. The PI nurse addresses the findings with the bedside nurse. Which statement by the bedside nurse indicates further teaching on advance directives is required? "The client denies having an advanced directive, and the information will be charted shortly." "The client's spouse is the healthcare power of attorney and is bringing the legal documentation." "The client is only being admitted for observation, so the information is unnecessary." "The client requested more information and is currently considering their options."

"The client is only being admitted for observation, so the information is unnecessary." Rationale: Information on advance directives should be requested from every client who is admitted to a healthcare facility regardless of the length of stay. The client's health status can change abruptly and healthcare providers should be aware of advance directives. Real-time charting is encouraged. However, the client has been appropriately assessed for advanced directives by the bedside nurse. A copy of the legal documentation should be included in the chart as soon as possible. Clients who do not have an advance directive should be provided with information that outlines their health care decision rights.

The nurse is using the SBAR technique to communicate with the health care provider. Which phrase would be associated with background (B)? "The client's treatments are..." "Vital signs are..." "I would like you to..." "I'm not sure what the problem is, but the client's condition is deteriorating."

"The client's treatments are..." Rationale: The correct option gives the health care provider background information about the client, including age, primary diagnosis, treatments, etc. Stating that the client's condition is deteriorating is the situation (S). Stating, "I would like you to..." is the request or recommendation (R). Vital signs are part of the assessment (A). Using SBAR is an effective technique used to improve communication with other members of the health care team. This in turn helps to foster a culture of safety.

The nurse is educating other staff members on the components of informed consent. When evaluating learning, which of the following responses indicates the need for additional teaching? Informed consent requires disclosure of risks." "The client must be able to understand the information needed to make a decision." "The client should describe the treatment or procedure they are giving consent for in their own words." "The provider should limit the amount of information provided, so the client isn't overwhelmed."

"The provider should limit the amount of information provided, so the client isn't overwhelmed." Rationale: In all health care facilities, informed and voluntary consent is needed for admission, for each specialized diagnostic or treatment procedures, and for any experimental treatments or procedures. Informed consent includes 1) disclosure, 2) comprehension, 3) competence, and 4) voluntariness. If the provider limits the amount of information provided, this must be done in a way that does not impact the client's right to self determination (autonomous decision making). The healthcare provider must always ask What would the average client need to know to be an informed participant in the decision?

A nurse is assessing a client after morning rounds. The client tells the nurse that the healthcare provider was rude and did not explain the plan of care. How does the nurse respond to the client's concern? "You are entitled to receive competent and respectful care." "Healthcare providers are very busy during morning rounds." "What questions do you have regarding your plan of care?" "Has your healthcare provider made you feel this way before?"

"You are entitled to receive competent and respectful care." Rationale: A client has a right to receive medical care from providers who are competent and treat the client with respect. The nurse acknowledges the client's concern. The nurse should not excuse the behavior of the healthcare provider. The client's questions regarding the plan of care should be answered. However, the nurse is not addressing the client's concern in its entirety. The nurse's role is to acknowledge the client's rights. Asking about past experiences does not address the current concern.

The nurse is performing an admission assessment for a client in labor. Her past obstetrical history reveals an elective abortion. The client states, "Please don't tell my husband." Which nursing response is best? "Your information is not shared without your consent." "You will have to fill out a form to protect your information." "You can tell your healthcare provider which information to protect." "You can leave that information off your records in the future."

"Your information is not shared without your consent." Rationale: The Health Insurance Portability and Accountability Act (HIPAA) provides for the maintenance of client confidentiality. There is no medical reason for the client's obstetrical history to be revealed at this time. The client has the right to decide when and if her past obstetrical history needs to be shared with her spouse. A client does not need to sign a form to protect their information; a form is used when the information is to be disclosed. Documentation of all past medical history in the electronic health record is appropriate and should be done to coordinate client care.

At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse see first? A 25-year-old client who is primipara, with cervical dilation of 1 cm and who is experiencing contractions 15 minutes apart. A 17-year-old client who is 18 weeks pregnant with a report of no fetal heart tones and coughing up frothy sputum. A 34-year-old client with a history of 2 prior vaginal term births and who is 2 cm dilated. A 28-year-old client who is grand multipara, 4 cm dilated and 50% effaced.

A 17-year-old client who is 18 weeks pregnant with a report of no fetal heart tones and coughing up frothy sputum. Rationale: The 17-year-old client is likely experiencing an actual complication of left-sided heart failure and a possible stillborn birth. The other clients have expected findings, or potential, but not actual, complications. The nurse should see the client who is coughing up frothy sputum first.

The triage nurse is evaluating several clients in a hospital's emergency department. Which client should be seen first? An adolescent who has soot over the face and shirt A middle-aged man with second-degree burns over the right hand A toddler with singed ends of long hair that extends down to the waist A 5-month-old infant who has audible wheezing and grunting

A 5-month-old infant who has audible wheezing and grunting Rationale: The nurse should use the A-B-C prioritization approach when determining which client to see first. The age and the findings suggest this client is at immediate risk for respiratory complications. The other clients are at a lesser risk for respiratory problems.

After receiving report on the following clients, which client should the nurse assess first? A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy A client diagnosed with emphysema with questions about a new medication A client who underwent a partial gastrectomy and reports feeling lightheaded A client reporting gastric distress after taking ibuprofen

A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy Rationale: Dizziness with PUD may indicate hemorrhaging. This client should be assessed including a symptom assessment and vital signs. The findings in the other options are expected and not life-threatening. A client may feel lightheaded due to dehydration and pain management related to a gastrectomy. Ibuprofen is a nonsteroidal anti-inflammatory drug, which has a common side effect of gastrointestinal symptoms. While educating the client on the new medication is important, it is not a priority for assessment.

A nurse is providing care to several clients on a medical unit. Which client would best benefit from an interdisciplinary conference? A client with newly diagnosed diabetes who uses a cane to ambulate A client with recurring wound infections who is homeless A client who requires short term antibiotics and is unemployed A client with a lower extremity fracture who has uncontrolled pain

A client with recurring wound infections who is homeless Rationale: A client with recurring wound infections who is homeless requires resources from several members of the interdisciplinary team. Case managers and social workers can assist the client with living arrangements while also providing follow-up care to prevent readmissions. A competent client can also learn wound care, often taught by physical therapists. A client who uses a cane to ambulate is still capable of managing a newly diagnosed medical condition. A client with financial difficulties who requires short-term medication use can be referred to pharmacy assistance programs. Uncontrolled pain can be managed in collaboration with the healthcare provider while the client is hospitalized.

A nurse is providing care to several clients on a medical unit. Which client will most likely require a referral to a registered dietitian? A client with stomach cancer who requires total parenteral nutrition A client with a small bowel obstruction who has a nasogastric tube A client with diverticulitis who has been NPO for two days A client with dysphagia who has a prescription for a puree diet

A client with stomach cancer who requires total parenteral nutrition Rationale: Total parenteral nutrition (TPN) has to be individualized to provide an adequate amount of nutrients to a client. A registered dietitian can provide input on the best formulation for a client with prolonged parenteral nutrition. A nasogastric tube is a short-term treatment for a small bowel obstruction. The treatment for diverticulitis is to keep the client NPO. A referral to a registered dietitian is not indicated at this time. The need for food to be pureed to prevent aspiration does not indicate a deficiency in nutrients.

A client has been referred to a skilled nursing facility for long-term medical care. The facility is requesting information on the client's pharmacological history and current treatment. Which will the nurse provide? The medication administration record The client's medical record A list of the client's home medications A medication reconciliation form

A medication reconciliation form Rationale: A medication reconciliation form provides information on the client's history of medications and current prescriptions. A medication reconciliation form should be provided with every referral or transfer to another facility or unit. The medication administration record only provides documentation of the current medications. The medical record provides information on the client's entire treatment. The facility is only requesting information on pharmacological treatment. A list of the client's home medications only provides pharmacological history, not current treatment.

The nurse is working as a triage nurse in an emergency department (ED) and prioritizes mandatory reporting for which of the following clients? A pediatric client with measles An adult client injured in a motor vehicle accident (MVA) An adolescent client with a non-fatal drug overdose An older adult with a recurrent urinary tract infection

A pediatric client with measles Rationale: The pediatric client with a communicable disease, such as measles, meets the requirement by law for mandatory reporting. Other guidelines for mandatory reporting include injuries with weapons, child abuse, and vulnerable adults. All of the other options do not meet the classifications of mandatory reporting.

The hospital has a mentor program for novice nurse managers. Which of these approaches is most likely to result in a positive experience for both mentor and mentee? The mentor is randomly assigned by administration. The mentee seeks clarification as needed. A teacher-coach role is used by the mentor. The mentee accepts feedback objectively.

A teacher-coach role is used by the mentor. Rationale: The mentor should adopt the role of teacher-coach. Teaching and coaching are essential elements of the professional role and will facilitate the transition from one role to another, e.g., from staff nurse to nurse manager. The mentor will also assist the novice manager to manage unfamiliar clinical situations and achieve a level of comfort in solving clinical/management problems.

An RN who usually works in a spinal rehabilitation unit is reassigned to the emergency department for a shift. Which of these clients should the charge nurse assign to this reassigned RN? A middle-aged client who says, "I took too many diet pills" and "my heart feels like it is racing out of my chest." A young adult who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a respiratory rate of 10 An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room A young adult who says, "I hear songs from heaven. I need money for beer. I quit drinking two days ago for my family. Why are my arms and legs jerking?"

A young adult who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a respiratory rate of 10 Rationale: The ED charge nurse should not assign the most critical and acutely ill clients, who require complex and highly-specialized care, to the nurse from spinal rehab. Instead, the ED charge nurse should assign clients whose conditions are more stable. The young adult (with a chronic condition) is exhibiting findings consistent with narcotic use/abuse/overdose. Even though this is an acute situation, this client's condition is more stable than the others, especially since the effects of the pain medication can be quickly reversed using naloxone. The other clients (the older adult who recently used crack cocaine, someone who is tachycardic or someone who may be experiencing DTs) all have potentially life-threatening conditions.

The triage nurse in an emergency room identifies that a 16-year-old client, who is legally married, has signed the consent form for medical treatment. Which action should the nurse take? Ask the client to wait until a parent or legal guardian can be contacted. Accept the consent form and proceed with the triage process. Refer the client to a pediatric hospital's emergency department. Obtain consent for treatment over the phone from the client's spouse.

Accept the consent form and proceed with the triage process. Rationale: Under the Statutory Guidelines for Legal Consent for Medical Treatment, a minor may gain the legal status of an "emancipated minor" through marriage. Therefore, this married client has the legal capacity of an adult. The triage nurse should allow the client to sign the consent form for treatment and proceed with the triage process. This client legally can consent to medical treatment independently, as an emancipated minor.

The nurse is planning the daily care for assigned clients. Which of the following tasks would be appropriate to delegate to the licensed practical nurse (LPN)? Administer a nasogastric tube feeding Initiate blood product administration Titrate an intravenous medication Perform an admission assessment

Administer a nasogastric tube feeding Rationale: LPNs cannot initiate blood product administration but may monitor the client after the initial administration has begun. LPNs also cannot titrate medications or assess clients. They can administer tube feedings, so this is an appropriate task to delegate.

The nurse is caring for a client who has prescribed albuterol via nebulizer and is feeling short of breath. The nurse calls the assigned respiratory therapist to administer the treatment, but the therapist is unable to come immediately due to an emergency. Which action is appropriate? Notify the healthcare provider. Stay with the client until the therapist arrives. Administer the prescribed albuterol via nebulizer. Instruct the client to use their personal albuterol metered dose inhaler.

Administer the prescribed albuterol via nebulizer. Rationale: Assignment and delegation abilities should not impact quality patient care. The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. Administering nebulized medications is within the nurse's scope of practice. There is no need to involve the provider at this time. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment not a metered-dose inhaler, so the nurse can't change the route without a new order from the healthcare provider.

The nurse on a medical-surgical unit is working with a team that consists of several other nurses and one unlicensed assistive person (UAP). Which tasks can the nurse delegate to the UAP? Select all that apply. Ambulate a client in the hallway twice a shift Assist a client in skeletal traction with meals and snacks Provide information about a low-sodium diet prior to discharge Obtain a daily weight on a client before breakfast Give a client on bed rest due to severe anemia a bed bath

Ambulate a client in the hallway twice a shift Assist a client in skeletal traction with meals and snacks Obtain a daily weight on a client before breakfast Give a client on bed rest due to severe anemia a bed bath Rationale: Unlicensed assistive personnel (UAP) are trained to assist with activities of daily living, such as bathing and dressing, collecting specimens, measuring weight, and assisting with ambulation. Teaching or providing discharge information can only be performed by a nurse.

The charge nurse is planning assignments on a surgical unit. Which activity should the charge nurse assign to the unlicensed assistive personnel (UAP)? Assist with meals and monitor ability to swallow following a mild stroke Apply compression stockings and ambulate in hall three times a day Change post-op hip dressing after removal of a drainage tube Review dietary needs with client prior to transfer to long-term care facility

Apply compression stockings and ambulate in hall three times a day Rationale: UAP can be assigned routine tasks that have predictable outcomes. Many of the tasks a UAP can do involve activities of daily living (ADLs), such as personal hygiene (shaving, bathing, oral hygiene, hair care, and toileting), assisting with dietary needs, and measuring vital signs. Sometimes a UAP may be allowed to change a dry, nonsterile dressing. Although UAP routinely assist clients with delivering and setting up food trays, UAP cannot assess a client's ability to swallow. Client teaching prior to discharge is a nursing responsibility.

A 65-year-old male client diagnosed with prostate cancer rates his pain level at 6 on a 0 to 10 scale. The client refuses all pain medication except for acetaminophen, which does not relieve his pain. Which action should the nurse take first? Talk with the client's family about the situation Ask the client further about the refusal of pain medication Report the situation to the health care provider Document the situation in the client's medical record

Ask the client further about the refusal of pain medication Rationale: Beliefs regarding pain are determined by socio-cultural norms, including age and gender. Nurses should investigate the meaning of pain to each client within a cultural explanatory framework. Astute observations and careful assessments must be completed to determine the level of pain the client is experiencing. Any action should be documented in the client's record, but this should occur after first speaking to the client. Should the client continue to have pain, the nurse may need to speak to the family and the health care provider.

The nurse working with an unlicensed personal assistant (UAP) to care for a client who has soft, bilateral wrist restraints placed. Which task should the nurse the perform? Observe the client's capillary refill. Assist the client in the bathroom every hour. Assess the client's skin underneath the restraints. Set up the client's meal trays and provide help with eating.

Assess the client's skin underneath the restraints. Rationale: A client who is in soft wrist restraints will require an assessment of skin and circulation, which is the responsibility of the nurse. The nurse can delegate to the UAP assisting the client to the bathroom and with eating and drinking.

A client continuously calls out to the nursing staff when anyone passes the client's door. He has various requests for assistance. The charge nurse should implement which intervention? Assign a nursing staff member to visit the client at regular intervals Reassure the client that a staff person will check frequently to see if the client needs anything Keep the client's room door cracked to minimize the distractions of people passing by the room Arrange for each staff member to go into the client's room to check on needs every hour on the hour

Assign a nursing staff member to visit the client at regular intervals Rationale: Regular, frequent, planned contact by a designated staff member is the best approach to provide a continuity of care and communicate to the client that care will be available as needed.

The charge nurse is making assignments on the day shift for a registered nurse (RN), a licensed practical nurse (LPN), and a certified nursing assistant (CNA). Which assignments are appropriate for a client who fell during the night, has a skin tear on the arm, a hematoma on the hip, and is scheduled for an X-ray of the hip? Select all that apply. Assign medication administration to the LPN Assign the CNA to assist with personal hygiene tasks Assign wound care to the RN Assign complete care to the LPN Assign the LPN to report confusion or headache

Assign medication administration to the LPN Assign the CNA to assist with personal hygiene tasks Assign wound care to the RN Assign the LPN to report confusion or headache Rationale: Since the client fell during the night, the RN should do the complete care and the wound care as these are opportunities to assess the patient's mental and physical status. The RN can assign certain duties to LPNs if the care is not too complex, and there is a low likelihood of complications resulting in an emergency. The LPN can administer medication and should report observations and data collection information to the RN. If the client remains stable, the CNA can assist the client with personal care activities.

A new nurse is delegating tasks to the unlicensed assistive personnel (UAP). If delegated, which task would require intervention by the nurse manager? Bathe a woman receiving brachytherapy with an internal radon device Assist an elderly client to the restroom Feed a 2-year-old with a broken arm Empty the urethral collection bag and provide perineal care

Bathe a woman receiving brachytherapy with an internal radon device Rationale: Caring for a client receiving brachytherapy with a radon implant and the associated hardware is complex. Additionally, movement of this client and exposure of healthcare workers to the radiation should be limited. The other tasks are simple and within the expectations of a UAP's duties.

Two members of the interdisciplinary team are arguing about the plan of care for a client. Which strategy could be used to de-escalate the situation? Tell the team members they must calm down and be reasonable. Adjourn the meeting and reschedule when everyone has calmed down. Bring the communication focus back to the client Interrupt, apologize for the interruption and change the subject.

Bring the communication focus back to the client Rationale: Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is an effective de-escalation strategy because it is an example of effective communication and collaboration. The other options are non-productive and may even make the situation worse.

The nurse is using the fax machine to transmit a client's laboratory results to another facility. Which action should the nurse take? Dial the number directly into the fax machine Enable the fax machine to save a copy Clearly label the results with identifying information Call the facility to verify receipt of the fax

Call the facility to verify receipt of the fax Rationale: When faxing any protected health information, the nurse should use pre-programmed numbers to prevent misdialing, attach a cover sheet that provides the identifying information, ensure that the fax machine does not save copies, and ask the sender to verify that the fax was delivered to the intended person.

A charge nurse is preparing the staffing assignment for the oncoming shift. Two nurses have called in and the client-to-nurse ratio will increase from 1:5 to 1:8. Which action does the charge nurse take? Call the nurse manager to report the situation before the end of the shift Ask the staff nurses to volunteer to work a double shift Finalize the staffing assignment for the oncoming shift Ensure all client care has been completed before the end of shift

Call the nurse manager to report the situation before the end of the shift Rationale: The nurse must report the situation to the nurse manager. A significant increase in nurse-to-client ratios can pose a risk to client safety. Asking the staff nurses to volunteer to work a double shift is not a safe practice and is not a decision that can be made independently by the charge nurse. Finalizing the staffing assignment disregards the risk of client safety concerns. Ensuring all client care has been completed on the unit before the end of the shift is not a realistic goal. Client care is continuous.

The nurse is caring for a client who is being transferred to the operating room (OR) for hip surgery. The client reports to the nurse that they did not mark the operative hip with the surgeon. Which action should the nurse take first? Proceed with transferring the client to the OR. Perform a "time out" so the site can be marked before the client is in the OR. Call the surgeon to mark the site with the client before transfer to the OR. Have the client mark the site before the transfer to the OR.

Call the surgeon to mark the site with the client before transfer to the OR. Rationale: According to The Joint Commission, the surgical site should be marked by both the client and the surgeon before anesthesia is administered and surgery begins when the surgery involves a specific side.

The nurse is caring for a pediatric client who is being evaluated for cystic fibrosis. When collecting data to develop a plan of care, the nurse should give priority to which finding? Caregiver states stools are bulky and greasy Weight of client is below the 50th percentile on the growth chart Caregiver reports frequent history of recurrent respiratory infections Activity intolerance and fatigue are reported with exercise

Caregiver reports frequent history of recurrent respiratory infections Rationale: The nurse should give priority to respiratory issues (ABCs) in the plan of care of a client with a possible diagnosis of cystic fibrosis. Due to the genetic dysfunction of the protein CFTR, the transport of chloride across the cellular membrane is disrupted resulting in thick tenacious secretions in the lungs and digestive tract. Due to malabsorption, stools may be bulky and greasy in nature. Malabsorption issues may also result in weight loss and failure to thrive. Activity intolerance and fatigue reported with exercise are related to respiratory complications of this disease.

The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN) and a certified nursing assistant (CNA). When making assignments, which team member should the nurse assign to measure and document vital signs for medically-stable clients? Unit secretary or clerk Licensed practical nurse Registered nurse Certified nursing assistant

Certified nursing assistant Rationale: Certified nursing assistants (CNAs) are unlicensed assistive personnel (UAP) who perform routine tasks that have predictable outcomes, which is why CNAs can be assigned to measure and document vital signs for medically stable clients. Before making this assignment, the charge nurse must know that the CNA has received the appropriate training and is competent to perform the activity. Also, a fully-qualified nurse must be available to provide supervision during the performance of any assigned task.

The nurse is making assignments for the unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP? Adjust the rate of a gastric tube feeding Ask a client receiving chemotherapy about pain Check the blood pressure of a two-hour postoperative client Record a history on a newly admitted client

Check the blood pressure of a two-hour postoperative client Rationale: UAPs must be assigned tasks that are routine, have expected outcomes, and require no nursing judgment or decision-making situations. Vital signs on stable clients are commonly assigned to unlicensed staff.

The nurse is preparing to administer a client's intravenous medications concurrently. Which action by the nurse is appropriate at this time? Mix the two medications in the same syringe Add one of the medications to the maintenance fluid bag Administer a liter bolus of normal saline between each medication Check the facility's medication compatibility reference

Check the facility's medication compatibility reference Rationale: Before giving medications concurrently, the nurse should access the facility's medication compatibility resource to check for any medication incompatibilities between medications/fluids. The nurse should not mix multiple medications in one syringe or add a medication to the maintenance fluids unless the prescription includes these instructions. Administering a liter of normal saline between each medication is not necessary and may cause complications related to excess fluid volume.

A nurse is providing care to a client with a do not resuscitate (DNR) advance directive. The nurse enters the client's room and finds the client unresponsive in bed. Which action does the nurse perform next? Initiates chest compressions Applies supplemental oxygen to the client Checks the client's pulse Contacts the healthcare provider

Checks the client's pulse Rationale: The nurse checks the client's pulse to confirm the absence of circulation. Although the client has a do not resuscitate (DNR) advance directive, the nurse must still confirm the client's condition. Initiating chest compressions goes against the client's advance directive. Applying supplemental oxygen to the client provides comfort measures. However, the nurse must first confirm the client is unresponsive. Contacting the healthcare provider is an important intervention after the nurse confirms the client's condition.

The healthcare provider requested an interpreter for a client who is deaf to obtain consent for surgery. The nurse knows that this request is based on which legal consideration? Compliance with the American Disabilities Act (ADA) of 1990 Mandate from the National League for Nurses (NLN) Approval from the Board of Nursing Advice from the hospital's legal counsel

Compliance with the American Disabilities Act (ADA) of 1990 Rationale: In addition to following facility policies and procedures, nurses must follow and comply with any federal and state laws relating to interpreters and serving as an interpreter. The American Disabilities Act (ADA) of 1990 prohibits and forbids any discrimination against any people with disabilities including those who are deaf. A sign language interpreter could be used in a healthcare organization to comply with this law. The National League of Nurses (NLN) is a national organization for faculty nurses and leaders in nurse education and not the basis for legal consideration. A board of nursing does not need to give approval for an interpreter for a client that is deaf. Advice from a hospital's legal counsel does not pertain to the legal consideration for use of an interpreter.

The nurse is caring for a client with end-stage renal disease (ESRD) and notices that the client has a regular diet ordered. Which action would the nurse perform next? Advise the client to follow their home diet Contact the dietary department to adjust the diet Contact the healthcare provider for diet orders Advise the non-licensed personal to hold the client's food tray

Contact the healthcare provider for diet orders Rationale: The client with ESRD should be placed on a renal diet that likely includes a fluid restriction. Fluid volume deficits and fluid volume overload are very common issues that arise in this client population. The nurse's first action should be to contact the healthcare provider to get specific diet orders that may need to correlate with the client's dialysis orders. The nurse should educate the client on following the diet they had at home, but the order in the client's medical record should be appropriate. The non-licensed personal should not hold the client's meal tray without proper cause, and the dietary department should be contacted after the order is received from the HCP.

A nurse is witnessing a surgical consent for a client. The client tells the surgical resident that they need time to think about the risks of the procedure. The resident tells the client there is no time to discuss the consent further. The client hesitantly signs the consent. Which action does the nurse take next? Signs the consent as a witness Informs the charge nurse of the situation Tells the client the consent is not valid Contacts the surgical attending

Contacts the surgical attending Rationale: The nurse should contact the surgical resident's supervisor or attending. The client's concerns and the resident's behavior should be addressed thoroughly before the procedure occurs. Signing the consent as a witness disregards the client's concerns about the risks of the procedure. Informing the charge nurse of the situation should occur after the nurse addresses the concern with the resident's supervisor. Telling the client that the consent is not valid after it has been signed does not address the ethical issue.

The nurse is preparing to call the healthcare provider regarding a change in the client's condition. The nurse understands to ensure effective communication, which information should be given first? Recommendation Current situation Clinical background Client preferences

Current situation Rationale: When calling the healthcare provider, the nurse should always be sure to organize information in a manner to facilitate good communication. The SBAR form of communication is recommended and widely used. The first thing communicated using this method is the current situation or what is happening with the client. The recommendation of the nurse is the last portion of the communication. The clinical background of the client should be given after the current situation. In this case, the client's preferences may not be a priority but can be added to the assessment portion of the communication.

A nurse manager has emphasized the use of bedside reporting to unit nurses. Which client outcome indicator suggests the performance improvement strategy is effective? Customer service reports indicate increased client satisfaction with nursing communication. Charge nurse rounds indicate over 80% of unit nurses are performing bedside reporting. Timesheets indicate nursing overtime has decreased by 10% on the unit. Nurses voice bedside reporting improves their workflow throughout the shift.

Customer service reports indicate increased client satisfaction with nursing communication. Rationale: The goal of bedside reporting is to improve communication amongst healthcare providers and ensure that the client is informed about their plan of care. Increased client satisfaction with nursing communication indicates bedside reporting is successfully meeting performance improvement goals. The number of nurses performing bedside reporting is a process indicator, not an outcome indicator. The primary goal of bedside reporting is to improve communication, not decrease overtime. Nurses voicing improved workflow is not a client-centered outcome indicator.

The nurse is auditing documentation in clients' medical records. Which entry in a client's progress notes is the most complete? Client expresses anxiety about a low-salt diet Client's urinary output adequate for the past shift Demerol 75 mg administered for severe abdominal pain Dark green drainage 100 mL from nasogastric tube at 0600

Dark green drainage 100 mL from nasogastric tube at 0600 Rationale: Documentation reflects the client's condition and the care they've received during their hospitalization. Documentation needs to be complete, accurate and objective. Reimbursement from third-party payers is facilitated when documentation is accurate, reliable and valid. Nurses need to adhere to good documentation standards, as it minimizes a nurse's chance of being named in a malpractice lawsuit. The word "anxiety" in the answer choice could be defined more specifically, along with the inclusion of information about the nurse's response. The medication order lacks the route, frequency and the client's response to the medication. The description of the nasogastric drainage is the most specific and factual. The criteria for "adequate" urinary output needs to be defined.

The charge nurse is informed about a conflict between two unlicensed assistive personnel (UAP) on the unit. Which approach is most appropriate to achieve effective conflict resolution? Encourage the UAPs to '"vent" their anger. Require the UAPs to meet 1-on-1 until they reach a compromise. Explain the consequences of not resolving their differences. Deal directly with the conflict affecting the workplace.

Deal directly with the conflict affecting the workplace. Rationale: When managing conflict in the workplace, it is most important to deal with the issue directly. The conflict occurs, it should not be minimized or ignored. When there is a conflict, people tend to feel angry and although "venting" may feel good, is is usually counterproductive. Forcing the UAPs to reach a compromise is not appropriate. If necessary, potential consequences of not resolving the conflict between the UAPs should be discussed.

The nurse is caring for a client who is the mother of a close friend. The friend asks the nurse for an update about their mother's condition on a social networking website. How should the nurse best respond? Do not disclose any information to the friend on the social networking website. Do not disclose any information to the friend on the social networking website. Answer the question on the social networking website because only trusted contacts can access the information. Respond on the social networking website, directing the friend to ask the question in person.

Do not disclose any information to the friend on the social networking website. Rationale: A nurse cannot disclose information about a client except to those who are directly involved in the care of the client. Also, clients must be informed about how their personal health information will be used and given the opportunity to object to or restrict the use or release of information. Nurses cannot use social networking websites, like Facebook, to disclose patient information, even with the use of privacy settings or when no names are used. Each health care organization has strict policies prohibiting the disclosure of protected health information.

The nurse is planning care for a client who is experiencing shortness of breath upon exertion. Which intervention should the nurse include in the plan of care? Increase intravenous fluid intake. Encourage rest periods during activity. Avoid ambulation as much as possible. Maintain a clear liquid diet.

Encourage rest periods during activity. Rationale: The client who is experiencing shortness of breath with exertion should rest often during activities. The nurse should plan for these rest periods and ensure that the client has the ability to pace themselves and a place to sit while performing activities. Ambulation should still occur if the client can tolerate it. Increasing IV fluids and maintaining a clear liquid diet do not address the client's shortness of breath.

The nurse provided staff education on the client's right to self-determination. Which of the following actions by a staff nurse demonstrates support of self-determination? Provides a client with educational materials written at the 12th grade level Encourages a client to ask questions when the healthcare provider is explaining the risks and benefits of a treatment Influences a client to continue to receive a painful treatment Advises the client of the nurse's own personal preference in healthcare providers

Encourages a client to ask questions when the healthcare provider is explaining the risks and benefits of a treatment Rationale: Clients have a right to determine what will be done with and to their own person, to be given accurate, complete, and understandable information in a manner that facilitates an informed decision, and to be assisted with weighing the benefits, risks, and available options in their treatment. They have the right to make these decisions without undue influence, duress, coercion, or prejudice and to be given necessary support throughout the process.

The nurse is performing an initial skin assessment on a client transferred from a different unit. The nurse observes redness to the gluteal folds. How should the nurse document the finding? Blanching Erythema Pressure injury Atrophy

Erythema Rationale: The initial sign of pressure is redness of the skin, which is called erythema. Blanching is seen when whiteish coloration of the skin remains longer than normal when pressure is applied. A pressure injury is evaluated and staged accordingly, and erythema is not classified as a pressure injury. Atrophy refers to the decrease in the size of an organ, body part, or tissue.

The nurse is preparing to discharge a client from the outpatient surgery center. Which action by the nurse promotes a safe discharge? Change the client's surgical dressing Provide instructions in writing Medicate the client for pain before leaving Evaluate who will be taking the client home

Evaluate who will be taking the client home Rationale: Clients who have surgery in the outpatient center go home the same day following surgery. The nurse should evaluate who will be taking the client home and ensure the client will have someone monitoring them for the first 24 hours. Prior to discharge, the client should receive written and verbal instructions in the language of their preference on follow-up care. The instructions for dressing changes should be given by the healthcare provider and followed. The nurse should avoid giving a client any medication prior to leaving to prevent any adverse effects.

The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving initiative. In order to prepare for the "unfreezing" phase of change, which approach would be best for the nurse manager to take? Clarify what the changes mean to the community and the hospital Discuss with the staff how to deal with any defensive behavior Explain to the unit staff why change is necessary Assist the staff for an acceptance of the new changes

Explain to the unit staff why change is necessary Rationale: The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it and explains this to the staff. The phase is completed when the staff comprehend the need for change.

The nurse is teaching a client about a procedure to be done in the home. The client requires an interpreter. When using the interpreter, the nurse should take which of the following approaches? Face the client while presenting the information as the interpreter talks in the native language Speak directly to the interpreter while presenting information, but allow the client time to ask questions Talk to the interpreter in advance, and leave the client and interpreter alone Include a family member in the teaching session, and speak only to them

Face the client while presenting the information as the interpreter talks in the native language Rationale: Communication is the cornerstone of an effective teaching plan, especially when the nurse and client do not share the same culture. Interpreter services reduce liability, increase client satisfaction, and improve client outcomes. Even if the nurse uses an interpreter, it is still critical that the nurse uses personal spacing, eye contact, and touch that are acceptable to the client. Therefore, to face the client and present the information to them allows the interpreter to translate the content. Facing the client also allows nonverbal communication to take place between the nurse and client. This could also be perceived as a sign of respect. It would be important to allow a family member to be present during the session to help reinforce content with the client. However, the family member should not relay critical information to the client firsthand. Leaving the interpreter and client alone is not appropriate. The nurse needs to be present to field questions in real-time and ensure that the interpreter relays all pieces of information accurately.

The nurse is planning a family care conference for a client who will be returning home with new medical needs. Which of these aspects of the discharge planning evaluation should receive priority consideration? Family's understanding of the client's health care needs Client's health insurance and prescription coverage Availability of community-based services Coordination of follow-up care with interdisciplinary team

Family's understanding of the client's health care needs Rationale: Family members must be willing and able to provide the required care at the times needed and understand the client's health care needs before the client is discharged home. The discharge planning evaluation will take into account a wide variety of information, such as the home environment, and the availability of community-based services (such as support groups, hospice, or medical equipment and related supplies, etc.) Family members should understand the financial implications of discharge, including health insurance and prescription coverage.

A healthcare provider requests home care services for a client who needs assistance with activities of daily living. How will the nurse initiate the request? Print out the latest laboratory report. Fill out a referral form. Scan the medical record. Complete a medication reconciliation.

Fill out a referral form. Rationale: A referral form provides the home care service with the necessary information to evaluate the client's needs. The nurse should follow the referral process according to facility policy. A laboratory report is not relevant to the client's need for home care services. Scanning the medical record is not indicated at this time. The first step in a referral process is to fill out a facility referral form for evaluation of the client's needs. A medication reconciliation is a standard process upon admission and at discharge; however, this step is not indicated for the provider's home care request.

Upon completing an admission, the nurse identifies that an older adult client does not have an advance directive. Which action should the nurse take? Refer this issue to the nurse manager and the risk manager Give the client written information about advance directives Document this information on the chart Assume that the client wishes full resuscitation efforts

Give the client written information about advance directives Rationale: For each admission, nurses should request a copy of a client's current advance directive. If there is none, the nurse must provide written information about what an advance directive implies. It is then the client's choice to sign the forms. Note that a standard is for non-direct care providers to witness these forms; a social worker or other health care professional would need to witness a client's signature.

The unlicensed assistive person (UAP) reports to the nurse that a client has a blood pressure of 78/46 mmHg and a pulse of 116 beats per minute. Which action should the nurse take first? Go to the client and perform a quick, focused assessment Activate the facility's rapid response team Increase the rate of the client's continuous IV infusion Instruct the UAP to place the client in a modified Trendelenburg position

Go to the client and perform a quick, focused assessment Rationale: The nurse should follow the nursing process and first see the client right away and perform a quick, focused assessment including the level of consciousness, breathing, and cardiac status. The assessment findings will help the nurse in making a clinical decision on what step would be most appropriate to take next.

Which statement describes factors that help build personal power in an organization? Credibility to one's position is enhanced when professional dress and demeanor are employed High visibility and formal power are maintained with a confrontational style Longevity in an organization, associating with people in power positions, and a history as someone who does not back down. Goals are met with the use of networking, mentoring, and coalition building

Goals are met with the use of networking, mentoring, and coalition building Rationale: Networking, mentoring, and coalition building are positive uses of personal power to meet goals.

The nurse is caring for a client who requires an orthotic due to a musculoskeletal disorder. Which of the following tasks can the nurse delegate to an unlicensed assistive person (UAP)? Select all that apply. Help the client with putting on the orthotic. Evaluate the client's response to ambulatory activity. Report any redness or signs of skin breakdown. Assist the client with transferring from the bed to a chair. Encourage the client's independence in self-care.

Help the client with putting on the orthotic. Report any redness or signs of skin breakdown. Assist the client with transferring from the bed to a chair. Encourage the client's independence in self-care. Rationale: The nurse cannot delegate any part of the nursing process. Monitoring the client's response to interventions requires evaluation, a task that can only be performed by the nurse. The other options are typically within the scope of a UAP and can be assigned and performed independently by the UAP.

The nurse is handing-off the care of a client admitted with pneumonia to the nurse for the next shift. Using the S.B.A.R. method, what client information should the nurse include in the hand-off report,? Pain, oxygen requirements, insurance information and vital signs IV access, admitting diagnosis, allergies and antibiotics given Admitting diagnosis, vital signs, room number and insurance information Marital status, vital signs, religious affiliation and admitting diagnosis

IV access, admitting diagnosis, allergies and antibiotics given Rationale: S.B.A.R. stands for situation, background, assessment and recommendation. Situation in the model refers to the client's main problem. Background refers to the client's basic information, such as admitting diagnosis, allergies, etc. Assessment refers to objective and subjective data the nurse collects that helps to define the client's problem. Recommendation is the nurse's suggested solution(s) to the problem. Insurance information, marital status and religious affiliation are not shared when using the S.B.A.R. model of communication.

The nurse is caring for a client who is two days post-surgery and notes that the client is experiencing a new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take? Educate the client's family on how to create a calm and safe environment for the client Inform the client's health care provider about the change in the client's condition Collaborate with the dietitian to identify ways to increase protein in the client's diet Encourage the client to schedule a follow-up appointment with their primary care provider

Inform the client's health care provider about the change in the client's condition Rationale: Delirium is considered a temporary but acute condition, which is often characterized by sudden confusion, agitation, and disorganized thinking. Factors that have been known to precipitate delirium include pain, dehydration, surgical procedures, and opioid administration. Clients who are at the highest risk for developing delirium are older hospitalized clients and clients who are admitted to intensive care units. All answer choices are plausible, but the best action for the nurse to take would be to inform the health care provider of the client's change in condition. It is imperative that delirium is recognized early as its causes are potentially reversible. Part of the client's plan of care would be to also instruct the client and family to schedule a follow-up visit with the primary care physician (PCP), develop a safe home environment, and maintain ample protein intake to facilitate wound healing.

The nurse is reviewing the health record of a client scheduled for surgery. Which of the following is a priority for the nurse to ensure is present in the record? Proof of immunizations Type and screen Advance directive Informed consent

Informed consent Rationale: A preoperative checklist is often used to outline the nurse's responsibilities on the day of surgery; these activities must be completed and documented before the patient is transported to surgery. The first item on the checklist is often to check that consent forms are signed and dated, witnessed, and correct. During the preoperative phase the priority is to ensure informed consent has been obtained for the surgical procedure. While other documents and tests on the checklist are important, this is the most important data for the nurse to collect currently.

A nurse receives admission prescriptions for a client with suspected sepsis. Which prescribed intervention will the nurse perform first? Initiation of intravenous fluids Collection of blood cultures Insertion of an indwelling urinary catheter Administration of a prophylactic anticoagulant

Initiation of intravenous fluids Rationale: The nurse should initiate intravenous fluids as soon as possible. Priority interventions for a client with suspected sepsis include fluid resuscitation and antibiotic administration. Obtaining blood cultures is an important intervention for determining the suspected source of infection. However, fluid resuscitation is the priority intervention. Insertion of an indwelling catheter and administration of prophylactic anticoagulants are routine interventions for a client with suspected sepsis. However, fluid resuscitation is the priority.

The intensive care unit had an increase in falls from last quarter. To help improve patient outcomes, the nurse recommends including physical therapy during department meetings. Which type of process has the nurse recommended? Patient-centered care Care mapping Interprofessional collaboration Care bundles

Interprofessional collaboration Rationale: Interprofessional collaboration involves multiple healthcare disciplines working with clients, families, and communities to improve outcomes. Inviting physical therapy to join the team to invoke change in the unit is an example of this form of collaboration. Patient-centered care is focused care plans based on the client's specific outcomes. Care mapping is a form of evidence-based practice in the form of clinical guidelines. Care bundles are used in the acute care setting, and many of them are a part of the nurses' scope of practice and can be implemented once the bundle is ordered by the healthcare provider.

The nurse overhears an unlicensed assistive personnel (UAP) tell a family member, "The client that injured your spouse in the motor vehicle accident (MVA) should go to jail, but he just died." Which action should the nurse implement first? Interrupt the conversation, and discuss the situation with the UAP privately Allow the UAP to finish her conversation, and discuss the situation later Apologize to the family member for the UAP's comments Tell the UAP that the comment is a violation of confidentiality

Interrupt the conversation, and discuss the situation with the UAP privately Rationale: The nurse should stop the conversation immediately and ask the UAP to discuss the situation privately, so the nurse does not embarrass the UAP. Gossiping about another client is a violation of his or her privacy and a breach of confidentiality and HIPAA protocol. The nurse should not allow the conversation to continue. The nurse could apologize for the UAP's comments, but this is not the first intervention. The nurse should tell the UAP about the breach of confidentiality but addressing the situation with her privately and immediately is the priority intervention.

The charge nurse is making assignments for a registered nurse (RN), a licensed practical nurse (LPN) and an unlicensed assistive person (UAP). Which assignment would make best use of the LPN's skills and abilities? Irrigate a wound and reapply a dressing. Admit a client from the emergency department. Assist with ambulating a client for the first time after surgery. Test a stool specimen for occult blood.

Irrigate a wound and reapply a dressing. Rationale: Although LPNs learn about the nursing process and can assess clients, the role of the LPN is typically supportive. The RN would be responsible for admitting a client and for assessing the client's ability to stand and walk after surgery. Both UAPs and LPNs can collect specimens; however the UAP cannot perform procedures requiring sterile technique. Therefore, the UAP could test the stool for occult blood and the LPN would perform the dressing change.

A group of nurse managers is tasked with making several important staffing decisions. Which statement describes the advantage of using a decision grid to make decisions? It is the fastest way for group decision-making It is both a visual and a quantitative method of decision-making. It allows data to be graphed for easy interpretation. It is the only truly objective way to make a decision in a group.

It is both a visual and a quantitative method of decision-making. Rationale: A decision grid allows the group to visually examine alternatives and evaluate them quantitatively or more objectively. It does not necessarily make the decision-making faster or interpretation easier. There are other tools available to aid in decision-making by a group.

The nurse is caring for a client diagnosed with trichomoniasis. The nurse administers a large dose of antibiotic and notices the following doses scheduled for tomorrow. The nurse documents the dose administered as which of the following? Partial dose Preventative dose Loading dose Tertiary dose

Loading dose Rationale: Trichomoniasis is a protozoal bacteria that causes a common sexually transmitted infection that can be treated in a variety of ways. Giving the antibiotics in a large single dose is considered a loading dose and can be followed by subsequent doses. A partial dose would indicate that a full dose was not administered, and this could indicate the need for an additional dose to make a full dose. A preventative dose would be given without prior to actual diagnosis of the bacteria. Tertiary refers to a stage of disease and of medication.

While caring for a client after lumbar spine surgery, which action can the nurse on the ortho-spine unit delegate to the unlicensed assistive person (UAP)? Log roll the client from side to side every two hours Check the client's ability to plantar and dorsiflex the foot Determine the client's readiness to ambulate Ask about pain control with the patient-controlled analgesia (PCA) Rationale: Repositioning a client is included in the training of UAPs. UAPs working on a specialty unit, such as ortho-spine, will be familiar with how to maintain alignment for a postoperative spinal surgery client. Evaluating the effectiveness of pain management, assessing neurologic function, such as plantar and dorsiflexion, and evaluating a client's readiness to ambulate after surgery require higher-level nursing education and scope of practice and, therefore, cannot be delegated to UAPs.

Log roll the client from side to side every two hours Rationale: Repositioning a client is included in the training of UAPs. UAPs working on a specialty unit, such as ortho-spine, will be familiar with how to maintain alignment for a postoperative spinal surgery client. Evaluating the effectiveness of pain management, assessing neurologic function, such as plantar and dorsiflexion, and evaluating a client's readiness to ambulate after surgery require higher-level nursing education and scope of practice and, therefore, cannot be delegated to UAPs.

The nurse is providing an in-service to graduate nurses on the risk of malpractice litigation. Which is the best strategy to decrease personal risk in the healthcare environment? Discuss any errors with the client and family in detail Keep incident reports on file Carry personal malpractice insurance Maintain expertise in practice

Maintain expertise in practice Rationale: Maintaining expertise in practice fosters continued competence in current knowledge and skills which is the best way to reduce personal risk and malpractice litigation. Incident reports are filed with a healthcare agency but do not decrease the risk of malpractice litigation. Discussing errors in detail with the client and family does not reduce the risk of a malpractice claim. Although a nurse can carry personal malpractice insurance, it does not decrease the risk of malpractice litigation.

The nurse is working in the local health department, and over the last six months, there has been an increase in chlamydia infections. In order to help reduce the rates of infection, the nurse suggests which of the following for the next three months? Giving handouts to sexually active clients on discharge Making condoms accessible to clients on discharge Assessing the client's knowledge of sexually transmitted infections Assessing each client's knowledge of safe sex practices

Making condoms accessible to clients on discharge Rationale: Everyone who is sexually active is at risk for sexually transmitted infections. For the nurse to help decrease the instances of infection, providing condoms would be a noninvasive and private way to assist clients in safer sex practices. This would also allow non-clinical staff to assist with the intervention. Giving handouts, especially to minors, could induce shame or embarrassment. Assessing a client's knowledge could be difficult due to less-than-truthful responses due to confidentiality concerns. Intervention that does not require the client to engage their personal information is most helpful.

The nurse is caring for a client who had surgery 2 days ago and has a prescription to ambulate with assistance. The nurse does not assist the client with ambulation resulting in the client falling and sustaining injury. The nurse could be charged with which of the following? Assault Battery Negligence Defamation

Negligence Rationale: Negligence is when care is below the accepted standard that would be provided by a prudent person. A nurse is negligent when the duty of care is breached, and the client sustains an injury. Battery is intentional touching of someone without consent. Assault is the verbal threat of harm. Defamation is the publication of false statements that damage someone's reputation.

The nurse is reviewing the laboratory data for a client with aplastic anemia and notes a white blood cell count of 3000 mcL. The nurse should understand that the client is at risk for which condition? Leukocytosis Neutropenia Phagocytosis Erythropenia

Neutropenia Rationale: Neutropenia is caused by a decrease in the production of neutrophils or increased destruction of these cells. This can be caused by several medical conditions, such as aplastic anemia. Leukocytosis is an elevation of white blood cell count. Phagocytosis is the ingestion of bacteria and ameboid protozoans. Erythropenia is a reduction in the number of red blood cells.

The nurse is performing a vision screening on a client using the Snellen chart. Which is the correct way to document the findings? OD and OS OR and OL AS and AU ON and OT

OD and OS Rationale: Common abbreviations related to eye health include OD oculus dexter, right eye and OS oculus sinister left eye. To document both eyes, the abbreviation OU is used.

A nurse is evaluating the plan of care of a client on a patient-controlled analgesia (PCA) pump for intractable pain. The PCA delivery record indicates the client is attempting to deliver more doses than the prescribed delivery limits. How will the nurse document the care plan evaluation? Outcome not met - Client requires further education on the purpose of a PCA pump. Outcome not met - Client continues to require maximum doses of pain medication. Outcome met - Client demonstrates ability to use a PCA pump. Outcome met - Client is receiving an adequate amount of pain medication.

Outcome not met - Client continues to require maximum doses of pain medication. Rationale: The goal for a client with intractable pain is pain relief and adequate pain management. A client who attempts to deliver more doses than the prescribed limits on the patient-controlled analgesia (PCA) pump indicates their pain is not well-managed. The PCA usage record does not indicate a client's lack of understanding of the purpose of a PCA. The ability to use a PCA pump does not indicate the outcome has been met. A client who attempts to deliver more doses than the prescribed limit indicates their pain is not being adequately managed.

The home health nurse is developing a plan of care for a child with Duchenne muscular dystrophy. Which other disciplines should the nurse consider collaborating with to slow the progression and prevent complications of the disease? Select all that apply. Physical therapy Orthopedist Pulmonologist Dietitian Speech therapy Nephrologist

Physical therapy Orthopedist Pulmonologist Dietitian Speech therapy Rationale: Duchenne muscular dystrophy (DMD) is the most severe and common muscular dystrophy caused by a genetic mutation that results in degeneration of muscle fibers. The disease is progressive causing weakness and wasting of skeletal muscles resulting in disability and deformity. Clinical manifestations include trouble getting into a sitting or standing position, difficulty walking, frequent falls and delayed growth. Complications of DMD include respiratory compromise, cardiac failure, disuse atrophy and contractures. The goal of care is to slow the progression of the disease and implement interventions to help prevent complications. The care team should include physical therapy, speech therapy, cardiology, pulmonology, orthopedist and a dietitian. Nephrology is not part of the care team for management of DMD.

The nurse is caring for a client with altered mental status due to a urinary tract infection who is refusing antibiotic therapy. In order to help keep the antibiotic therapy on schedule, the nurse contacts which of the following? Pharmacy Power of attorney Healthcare provider Charge nurse

Power of attorney Rationale: A living will is a form of advance directive and can often cite a durable power of attorney, which is a person who is able to make healthcare decisions for the client in the case of incapacitation. This person often knows the wishes of the client. The HCP and pharmacy should be called if the power of attorney is not available to give consent to administer the medication. The charge nurse should be kept abreast of any delay in the care of any client but would not be the priority in this case.

The nurse is planning education for a client who is Spanish speaking and hard of hearing. The client's adult child is bilingual. What teaching method is essential for this client? Arrange for an interpreter to translate the lesson. Provide written materials in Spanish. Use hand gestures to communicate the meaning. Educate the client's family member

Provide written materials in Spanish. Rationale: Clients must be given oral and written educational material written at the client's reading level. In this case, written materials are even more important due to the hearing impairment. At times, written material is beneficial for clients and, at other times, the assistance and services of a professional translator may be indicated. An adult client should be educated directly and not only a family member. Use of a family member not trained in interpretation may lead to misunderstandings and confusion.

A nurse is providing care to a client in the emergency department who is homeless and is frequently admitted for emergent dialysis. The nurse understands that the client has the right to receive access to healthcare under which provision in the nursing code of ethics? Provision 2 Provision 5 Provision 7 Provision 8

Provision 8 Rationale: The scenario is an example of Provision 8 of the nursing code of ethics, which outlines the nurse's collaboration with other healthcare providers to protect human rights, see health as a universal right, and reduce health disparities. Provision 2 discusses the client being the nurse's primary commitment within the profession. Provision 5 outlines the nurse's duty to maintain professional competence and growth. Provision 7 states that nurses must advance the profession through professional development and scholarly inquiry.

The nurse is caring for an adult client who has a new diagnosis of diabetes type 2. The client states, "What would be the best way to keep my blood sugar low and help me lose weight?" Which member of the inter professional team should the nurse collaborate with to provide accurate information? Registered dietitian Diabetes educator Healthcare provider Exercise physiologist

Registered dietitian Rationale: A registered dietitian (RD) manages and plans for the dietary needs of patients based on knowledge about all aspects of nutrition. RDs can adapt specialized diets for the individual needs of patients, counsel and educate individual patients, and supervise the dietary services of an entire facility. Diabetes educators have expertise in insulin and oral hypoglycemic treatment regimens and can provide some information regarding diets. Exercise physiologists can provide techniques to exercise but do not address the need to control blood glucose levels.

The registered nurse (RN) is responsible for a client in isolation. Which nursing activity can be assigned to a licensed practical nurse (LPN)? Evaluating staff's compliance with infection control measures Observing for and removing risks in the client's room Assessing the client's attitude about infection control Reinforcing isolation precautions with visitors

Reinforcing isolation precautions with visitors Rationale: LPNs (and unlicensed assistive persons) can reinforce information that was originally given by the RN. The other options are RN responsibilities and cannot be delegated.

The nurse is working with unlicensed assistive personnel (UAP) to care for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy and is stable. Which action would be appropriate for the nurse to delegate to the UAP? Report SpO2 levels. Titrate oxygen flow rate. Educate client about oxygen use. Evaluate if client has dyspnea.

Report SpO2 levels. Rationale: Members of the healthcare team who are caring for clients receiving oxygen therapy have specific scopes of practice. The nurse is responsible for assessing the need for titration of oxygen flow rate, educating the client about oxygen use, and evaluating if the client has dyspnea. The nurse can delegate reporting the SpO2 levels to the UAP.

The nurse is caring for a client who has been admitted for a chronic respiratory condition exacerbation. Which of the following findings should be reported to the provider immediately? Oxygen saturation of 92% on room air Blood pressure of 128/90 mmHg Respiratory rate of 28 breaths per minute Heart rate of 95 beats per minute

Respiratory rate of 28 breaths per minute Rationale: The normal respiratory rate is 10-20 breaths per minute (bpm); therefore, a rate of 28 bpm needs to be reported to the provider as an abnormality. While the ideal oxygen saturation is 95% or higher, clients who have chronic respiratory conditions often have slightly lower oxygen saturation levels as a normal finding. The client's blood pressure and heart rate are not findings that need to be reported to a provider.

The nurse is caring for a client admitted with respiratory distress, and endotracheal intubation is indicated. Which member of the healthcare team should the nurse collaborate with to ensure the ventilator is set up and operational? Respiratory therapist Healthcare provider Biomedical services Charge nurse

Respiratory therapist Rationale: The purpose of mechanical ventilation is to maintain alveolar ventilation and oxygen delivery. Respiratory therapists are trained in techniques and equipment that improve oxygenation and pulmonary function, including ventilators. The healthcare team continually assesses the patient for adequate gas exchange, signs and symptoms of hypoxia, and response to treatment. Therefore, the nursing diagnosis of impaired gas exchange is, by its complex nature, multidisciplinary and collaborative. The team members must share goals and information freely.

The nurse is conducting an admission interview for an older adult client with altered mental status. . The nurse notes the client is poor historian. . Which action is the most appropriate for the nurse take to obtain the client's past medical history? Wait until the client can provide the information. Review information from previous admission in the medical record. Document that the client is unable to provide information. Check to see if there is contact information for family on the chart.

Review information from previous admission in the medical record. Rationale: The health history and assessment is conducted to determine the client's states wellness or illness. There are a variety of ways to collect data for an assessment and the nurse should ensure that the data is obtained from a reliable source. The client has altered mental status so the information obtained from the client could be inaccurate. The information should not be left blank until all resources are used to obtain the information. Obtaining the information from the neighbor could violate the client's privacy and should be avoided. Using the EMR, the nurse could look at the client's previous history.

The healthcare provider has identified the need for an infusion of packed red blood cells. When obtaining informed consent, what information should be included? Risks of transfusion related adverse effects Identity of the blood donor Information about the components of blood The process for crossmatching blood products

Risks of transfusion related adverse effects Rationale: In all health care facilities, informed and voluntary consent is needed for admission, for each specialized diagnostic or treatment procedures, and for any experimental treatments or procedures. The following are the required elements for documentation of the informed consent discussion: (1) the nature of the procedure, (2) the risks and benefits and the procedure, (3) reasonable alternatives, (4) risks and benefits of alternatives, and (5) assessment of the patient's understanding of elements 1 through 4. The identity of the donor is not available and is not shared. The client does not require a lesson on the components of blood during the informed consent process nor how blood is crossmatched.

The nurse is assessing a hospitalized client who speaks the nondominant language. The client's daughter is bilingual and present at the bedside. Which action by the nurse is most appropriate? Seek out a certified interpreter Utilize a picture board to communicate with the client Request that a bilingual nurse complete the assessment Ask the client's family member to interpret

Seek out a certified interpreter Rationale: Options for working with clients who do not speak the dominant language include requesting assistance from a certified interpreter or using a telephone-based interpreter. Using family members is not appropriate since it is a violation of the client's HIPAA rights. In addition, clients may not feel comfortable explaining their symptoms with a family member present, and medical terminology may not be translated correctly. Not asking essential questions may result in an incomplete assessment. A picture board may be used in an emergency but is inadequate for a thorough assessment.

The nurse is participating in collaborating with the interdisciplinary team for an assigned client. The nurse has identified that the client will need access to community resources after discharge. Which member of the team would be best equipped to address this need? Social worker Healthcare provider Charge nurse Nurse manager

Social worker Rationale: Based on the need, the appropriate team member to collaborate with would be the social worker. Making referrals to appropriate community resources is one of the roles of the social worker. All other members of the team play a role in addressing inpatient needs.

The nurse has received a report from the previous shift. Which of the following is the priority action for the nurse after receiving the report? Suction the airway of a client with thick secretions Confirm intravenous (IV) fluids and flow rates Replace the empty medication syringe in a patient-controlled analgesia (PCA) pump Obtain supplies for a bedside procedure

Suction the airway of a client with thick secretions Rationale: Following Maslow's Hierarchy of Needs, the priority action of the nurse after receiving the hand-off report is to maintain a patent airway and to suction the airway of a client with thick secretions followed by confirming intravenous (IV) fluids and flow rates and replacement of an empty medication syringe. The lowest priority, although important, is obtaining needed supplies for a bedside procedure.

The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse assign to an unlicensed assistive person (UAP)? Suggest foods that are high in iron and prepare a list for the client. Assess and document skin turgor and skin color changes. Test a stool sample for occult blood and report the results. Report mental status changes and level of mental clarity.

Test a stool sample for occult blood and report the results. Rationale: Unlicensed assistive personnel or persons (UAP) perform routine tasks that have known or expected outcomes because these tasks typically do not require nursing judgment or decision-making. Any nursing intervention that requires independent, specialized nursing knowledge, skill or judgment cannot be assigned to UAP.

Where can the nurse find the most reliable guidelines regarding the appropriate delegation of tasks to unlicensed assistive personnel (UAP)? The American Nurses Credentialing Center That state's nurse practice act (NPA) The National Council of State Boards of Nursing (NCSBN) The American Nurses Association (ANA)

That state's nurse practice act (NPA) Rationale: When questions arise regarding who can delegate what activities to which unlicensed provider groups, it is the nurse practice acts (NPAs) of individual states that establish the legal definitions of appropriate delegation practices. Because regulations differ among states, each nurse must identify and understand the regulations for the state in which they practice.

The nurse received a report on the following assigned clients. Which of the following pediatric clients should the nurse assess first? The child who is reporting pain at the site of an intravenous (IV) catheter The child whose parents are reporting has blue-tinged lips The child who keeps asking for their parent The child with a fever who refuses to eat

The child whose parents are reporting has blue-tinged lips Rationale: The nurse would first assess the child with blue lips and mucous membranes as this indicates cyanosis/respiratory distress. Reports of pain at the site of an intravenous catheter and a child who refuses to eat with a fever are not emergencies. Depending on the age of the child, separation anxiety should be anticipated and is not a medical emergency. The child with a fever who refuses to eat would be assessed next due to the risk of circulatory dehydration.

The nurse is caring for a 16-year-old client in the emergency department who requires informed consent for surgery. The 18-year-old spouse is at the bedside. Who will the healthcare team approach to obtain informed consent? The adult spouse The client One of the client's parents The client's legal guardian

The client Rationale: A married minor may be treated without parental or legal guardian consent. Other exemptions include, but are not limited to, pregnant minors, minors over a specific age being treated for sexually transmitted diseases, emancipated and mature minors such as those in the military and living apart from parents.

The nurse is assessing a client with a history of diabetes type II. Which finding would require the nurse to update the client's plan of care? The client requests to rotate fingers for blood glucose monitoring. The client reports numbness in feet when walking. The client asks for assistance with meal planning. The client requires a snack before physical therapy.

The client reports numbness in feet when walking. Rationale: Clients with diabetes are at risk for developing neuropathy, nerve damage that occurs from elevated blood glucose levels. Clients who have developed diabetic neuropathy will report numbness or tingling in the feet. The nurse will need to update the plan of care to prevent injury or further complications. A client who requests to rotate fingers is normal. A client may ask for assistance with meal planning. A snack before physical therapy is appropriate for a client with diabetes to prevent a hypoglycemic event with activity.

A nurse is preparing to refer a client with uncontrolled diabetes mellitus type 2 to a self-management education and support service. What supportive documentation will the nurse include with the referral? The client's latest hemoglobin A1C level A copy of the client's medical record The current capillary serum glucose level A record of the last physical assessment

The client's latest hemoglobin A1C level Rationale: The latest hemoglobin A1C level will help provide information on the client's compliance and efficacy of current treatment. A hemoglobin A1C level determines the average serum glucose level over a period of 3 months. The client's medical record will provide information on all medical history and treatment. A diabetes self-management and support service focuses on a specific diagnosis. The current capillary serum glucose level and the last physical assessment do not provide historical proof of uncontrolled diabetes.

A nurse is recalling the steps in the nursing process. During the evaluation phase for a client, the nurse should focus on which aspect? The client's status, progress toward goal achievement and ongoing reevaluation. Setting short- and long-term goals to ensure continuity of care from hospital to home. Select interventions that are measurable and achievable within selected timeframes. Findings of physical and psychosocial stressors of the client and in the family.

The client's status, progress toward goal achievement and ongoing reevaluation. Rationale: The evaluation step of the nursing process focuses on the client's status, progress toward goal achievement and ongoing reevaluation of the plan of care. The other possible answers focus on some of the other steps of the nursing process.

A nurse is providing care to a client post-hemorrhagic stroke. The client has history of hypertension, diabetes, and bipolar disorder. Which event would prompt the nurse to request an interdisciplinary conference? The nurse receives duplicate prescriptions from healthcare providers of different specialties. The client refuses to participate in physical therapy sessions. The client's family voices the inability to care for the client after discharge. The nurse notes multiple medications on the client's electronic medical record.

The nurse receives duplicate prescriptions from healthcare providers of different specialties. Rationale: A client with complex medical conditions may receive treatment from different healthcare providers and specialties. The nurse requests an interdisciplinary conference to prevent an overlap of medical treatment. A client who refuses physical therapy sessions would benefit from education regarding the benefits of mobility. Discharge planning can be referred to case management or social work. Multiple medications are expected for a client with several co-morbidities.

The nurse is admitting a client from a long-term care facility who is confused and unable to answer any questions. The client does not have any caregivers present. Which resource should the nurse utilize to obtain the most accurate information about the client? The verbal report from the transport team The client's recent laboratory reports The transfer form from the long-term care facility The prescriptions from the healthcare provider

The transfer form from the long-term care facility Rationale: The long-term care facility will send a transfer form with the client on admission with a detailed history, medication list, and other pertinent information about the client. The verbal report from the transport team will only provide a brief report and not the most accurate information needed for the client. The client's recent laboratory reports will only provide a glimpse of the client's condition and is not the most accurate. The prescriptions from the healthcare provider will include a diagnosis, but no information on the client's condition or medical history.

The clinic nurse is assisting with medical billing. The nurse uses the Diagnosis Related Group (DRG) manual for which purpose? To determine reimbursement for a medical diagnosis. To identify findings related to a medical diagnosis. To classify nursing problems from the client's health history. To implement nursing care based on case management protocols.

To determine reimbursement for a medical diagnosis. Rationale: DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment. The nurse uses this manual to determine reimbursement for medical diagnoses.

The nurse is coordinating care for a client with a left-sided hemiparesis who is being transferred from inpatient rehabilitation to a long-term care facility. Which document would best provide continuity of care? Recent medication administration record Transfer summary with in-patient history and plan of care Referral form for an occupational therapist Original medical record from the rehabilitation facility

Transfer summary with in-patient history and plan of care Rationale: A transfer summary would be the best document to provide continuity of care as it summarizes significant findings, the procedures performed and treatment rendered, the patient's condition on discharge or transfer, and any specific pertinent instructions. The original chart will not accompany the client, but copies or sections of the chart may be sent based upon agency protocols. A referral form for an occupational therapist may be needed, but is not the best way to provide continuity in care. Pertinent medications from the medication administration record (MAR) may be reviewed in the hand-off report with the nurse at the long-term care facility.

The nurse in the labor and delivery unit is giving a report to the nurse in the postpartum unit. Which is the most effective way for the nurse to ensure essential information about the client is reported? Give written report to the nurse. Audiotape the report for future reference and documentation. Document transfer information in the client's electronic health record. Use a printed checklist with information individualized for the client.

Use a printed checklist with information individualized for the client. Rationale: Using a checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a written report leaves no room for the receiving nurse to ask questions, and using an audiotape or an electronic health record requires nurses to spend unnecessary time retrieving information.

The nurse observes another nurse walking away from their computer with a client's electronic medical record (EMR) still visible on the screen. What should the nurse do first? Complete an incident report about the potential client privacy violation. Notify the nurse manager of the incident. Speak with the nurse about always closing the EMR. Walk over to the computer and close the client's medical record.

Walk over to the computer and close the client's medical record. Rationale: All of the nurse's actions are appropriate, but in order to prevent unauthorized personnel from seeing any of the client's protected health information, the nurse should first close the client's EMR, which is still visible on the screen.

The nurse is reviewing the laboratory data for a client with a history of hypertension who is taking prescribed hydrochlorothiazide. Which result would indicate to the nurse that the client would require a different treatment option? serum potassium 5.5 mEq/L BUN 16 mg/dL creatinine 1.2 mg/dL serum osmolarity 280 mosm/kg

serum potassium 5.5 mEq/L Rationale: HTN results in vasoconstriction and fluid volume overload, which can lead to kidney insufficiency. The client with kidney insufficiency will have an elevated serum potassium level, greater than 5.0 mEq/L. Normal BUN is 6-24 mg/dL, creatinine is less than 1.5 mg/dL, and serum osmolarity is 275-295 mosm/kg.