teamwork and collaboration prep u
A staff nurse is talking with a clinical nurse leader and asks, "What exactly do you do?" Which statement by the clinical nurse leader would be appropriate?
"I collaborate with health care teams to promote client care."
When caring for clients with disabilities, nurses need to understand not only pathophysiological issues but also the concept of disability. Which of the following statements to the client demonstrates that the nurse understands the concept of disability?
"I have collaborated with a social worker to assess your needs for after discharge."
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?
"I provide indirect care to my clients by coordinating their treatment with other disciplines."
A child is being discharged from the hospital and the nurse has completed discharge teaching regarding prescribed liquid medications. Which comments by the parent demonstrates understanding of discharge instructions for safe medication administration?
"I will be sure to not give too much of the liquid medication at one time." "I shouldn't use a liquid dropper from my kitchen because it may be a different measurement than one from the pharmacy." "I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I use for my B12 injections."
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."
A nurse is using the SBAR approach for handoff communication when transferring a client to the critical care unit. Which statement would the nurse include as part of the recommendation?
"The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes."
Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode should the nurse anticipate?
Adjuvant therapy is likely.
The new nurse is evaluating the effectiveness of the assigned nurse mentor. Which characteristic should the new nurse recognize as being inappropriate for the nurse mentor to role model?
Advising the new nurse to consult the nurse mentor before making decisions regarding client care
The health care provider orders NPH U100 insulin 16 units SC every AM for a client. The nurse prepares the insulin dose. To ensure safety, what does the nurse do?
Ask another nurse to double-check the measurement.
The nurse observes a physician leave the room of a client in isolation for infection with Clostridium difficile. The physician uses the alcohol-based hand sanitizer hanging on the wall to wash her hands and leaves the door open. Which action should the nurse take?
Ask the physician to wash her hands with soap and water.
A nurse is leading a group. During the session, the nurse observes the members testing each other to see if they can trust each other. The nurse leader also notes that the members are testing the nurse, too. The nurse interprets this behavior as characteristic of which phase?
Beginning
The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?
Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.
A registered nurse (RN) is receiving an admission to the medical-surgical unit. Which nursing responsibilities would be appropriate to delegate to the licensed practical/vocational nurse (LPN/VN) on the unit?
Collecting the IV pole and assessment equipment Assisting a client with incentive spirometry Preparing the bed and room for the admission
The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
Comatose
The working stage of group therapy is marked by which characteristic?
Conflict and cooperation among group members.
Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?
Consultation
The nurse is providing care for a patient in the hospital scheduled for discharge in the morning. The patient will require further services after discharge since recovery is not complete. What can the nurse do to ensure quality care delivery for this patient?
Contact the case manager for coordination of care prior to discharge of the patient.
A client tells the nurse that he is experiencing floaters in the eye. What is the appropriate nursing intervention?
Contact the physician
Which procedure uses liquid nitrogen to freeze tissue, thereby destroying cells?
Cryoablation
An informatics nurse specialist is working with a team who is developing an expanded system for documenting critical values in the electronic health record (EHR) being used at the facility. The team has identified the need for this addition and provided appropriate evidence to support this change. The team would now proceed to which phase in the system development lifecycle?
Design and build
The parent has brought a 2-year-old to the public clinic for immunizations. The nurse documents the following characteristics: A duck waddle gait Shortened extremity Asymmetry of the gluteal folds Protruding abdomen The nurse then refers the toddler to the health care provider for potential diagnosis of which?
Developmental dysplasia of the hip (DDH)
A patient has been diagnosed with congestive heart failure (CHF). The health care provider has ordered a medication to enhance contractility. The nurse would expect which medication to be prescribed for the patient?
Digoxin
Which is an appropriate nursing intervention in the care of the client with osteoarthritis?
Encourage weight loss and an increase in aerobic activity
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?
JVD is noted 4 cm above the sternal angle.
A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?
Notify the physician.
The nurse is caring for a child with disseminated intravascular coagulation (DIC). The nurse notices signs of neurologic deficit. Which nursing action is appropriate?
Notify the physician.
A mass casualty event has occurred in a community. Many health care workers have been employed to assist. A nursing student has volunteered services. With which tasks would the nursing student be asked to assist?
Obtain extra supplies, such as intravenous bags and tubing, dressings, and gloves. Take clients' vital signs. Hold pressure on a wound that will not stop bleeding.
A nurse is providing care to a toddler with nephroblastoma and is being evaluated. Which nursing action would be most important?
Placing a "no abdominal palpation" sign above the child's bed
The nurse is assessing a multipara client who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?
Prepare to assist with external version.
A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?
Relieved by rest and nitroglycerin
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?
Report the finding to the pediatrician.
The nurse admits a new client to the unit for elective surgery. What would be the best way for the nurse to facilitate the practice of religion for this client?
Respect the need for privacy during periods of prayer. Attempt to meet religious dietary restrictions. Arrange for the client's pastor to visit if desired.
A nurse manager best demonstrates effective leadership characteristic by which action?
Sharing a vision for the unit and enlisting support
The child life nurse practitioner has been assigned to assist the hospitalized child and the child's parents. Which interventions are appropriate for the child life specialist to perform?
Speaking to the physician as the child's advocate. Showing the child where the pediatric playroom is located. Talking to the family about a scheduled diagnostic test.
An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?
Support system
The nurse should intervene immediately when observing the nursing assistive personnel (NAP) performing which activity with a stable client?
Teaching a client range-of-motion exercises
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke
The presence of mucus and pus in the stools suggests which condition?
Ulcerative colitis
A group is trying to handle issues related to dominance, control, and power within the group. In what stage of group development is this group?
Working
A clinical nurse specialist developed clinical pathways for common orthopedic conditions. In which way should the interdisciplinary team use these pathways?
as guidelines to ensure continuity of care
Kaposi sarcoma (KS) is diagnosed through
biopsy
A newborn requires resuscitation secondary to asphyxia. The resuscitation team frequently assesses the newborn's response and continues resuscitation efforts based on which assessment finding?
heart rate of 70 beats/min
A client is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes?
including the client in developing a care plan that works toward meeting discharge goals
A group of nursing students is reviewing information about chromosomal abnormalities. The students demonstrate understanding of this information when they identify what as a common mechanism leading to an abnormal chromosome number?
nondisjunction
Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to:
prepare the client for home care.
Which concept should the nurse consider prior to a formal client referral to a therapeutic group?
the client's social skills
When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the health care provider?
"I really don't like to be in small, enclosed spaces."
A nurse is preparing for handoff communication for a client who is being discharged from the hospital to home health care. Which example is not an action performed during this process?
The nurse prepares the new room for the client.
While the nurse is recording the health history of a client who is scheduled for a thyroid test, the client informs the nurse about an allergy to seafood. What is the nurse's most appropriate response?
Document the allergy and inform the physician
A nurse is preparing a dose of insulin to give the client. Which action takes priority when preparing and administering this medication?
Double-check the dose with another RN before giving.
When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the health care provider has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present?
The nurse is operating under standing orders for clients with suspected MIs.
Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution?
The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.
Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant?
completion of range of motion on limbs restrained
Which statement regarding spiritual care providers in hospitals is most accurate?
Clergy, lay volunteers, and those with advanced spiritual care degrees can serve on the spiritual care team at hospitals.
The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider?
K+ 3.1 mEq/L
The nurse and nursing assistant are moving a client who slid down in the chair. What does the nurse encourage the assistant to avoid shearing when moving the client to a higher position in the chair?
Lift the client, do not slide them.
The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just don't feel good." What actions should the nurse take?
Stay with and reassure the client. Confirm the client's vital signs and complete a quick assessment. Call the health care provider (HCP) and report the situation using SBAR format. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. Place the client in the semi-Fowler's position.
A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which choice?
A referral.
A client comes to see the cardiologist for a routine follow-up visit. At the visit, the nurse reviews the client's electronic health record. The nurse is able to access a report from the client's last visit to the primary care provider last month and the report from an emergency department visit two weeks ago for reports of shortness of breath. The record also lists two changes in the client's medication based on the emergency department visit. The nurse's ability to access this information reflects which concept?
Interoperability
