Week 9 Leadership and Management

Which client retains the right to give informed consent? 1. A 21-year-old who is hearing and seeing things that others do not 2. A 32-year-old voluntarily admitted client who is severely mentally retarded 3. A 65-year-old client declared legally incompetent 4. A 14-year-old client with attention-deficit disorder (ADD)

1. A 21-year-old who is hearing and seeing things that others do not A diagnosis of psychosis does not mean that a client is unable to consent to treatment.

The nurse receives the following information about patients at the change of shift report. although all the patients should be assessed, indicate which two patients should be assessed before the others. 1. A patient who just was informed of having cancer 2. A patient who was complaining of feeling nauseated 3. A patient who is receiving a titrated medication via an infusion pump 4. A patient who received an analgesic by mouth for pain immediately before report 5. A patient whose vital signs include an irregular apical pulse and labored respirations

1. A patient who just was informed of having cancer 5. A patient whose vital signs include an irregular apical pulse and labored respirations 1 and 5 are correct in one this information may have precipitated a crisis for this patient. Psychosocial needs of patients are as important as physiologic needs and 5 these vital signs are outside the expected range; therefore, this patient should be assessed first because these adaptations may indicate a life-threatening situation. 2 is not correct as it is not life-threatening adaptation. Other patient situations are a greater priority. 3 although this patient should be monitored infusion pumps deliver fluid volumes safely. other patient situations are a greater priority. 4. An analgesic by mouth takes approximately 20 to 30 minutes to be effective. this patient's response to the medication can be evaluated after other patients' needs are met.

The nurse is teaching a class on disaster preparedness. Which are components of an Emergency Operations Plan (EOP)? (Select all that apply) 1. A plan for practice drills 2. A activation response plan 3. A plan for internal communication only 4. A pre-incident response 5. A security plan

1. A plan for practice drills 2. A activation response plan 5. A security plan

The nurse is working with community members in order to aid them in preparation for any disaster. She helps them compile a list of emergency supplies needed in case of a disaster. Which of the following would be included in the list? Select all that apply. 1. A three day supply of water and food that will not spoil 2. One change of clothing and protective footwear 3. Passport and birth certificate 4. Candles and matches 5. Sanitation supplies, including toilet paper, soap, feminine hygiene products, and plastic garbage bags.

1. A three day supply of water and food that will not spoil 2. One change of clothing and protective footwear 4. Candles and matches 5. Sanitation supplies, including toilet paper, soap, feminine hygiene products, and plastic garbage bags.

A nurse expert is called to testify in a lawsuit regarding professional nursing malpractice primarily to testify: 1. About standards of nursing care as they apply to the facts in the case 2. With regard to laws governing the practice of nursing 3. For the prosecution 4. For the defense

1. About standards fo nursing care as they apply to the facts in the case

A patient who had a total abdominal hysterectomy 2 days ago is ambulating and complains of dyspnea and stabbing chest pain on inspiration. A nursing assessment reveals a pulse of 110 and respirations of 35. While many of the following actions may be implemented, which three take priority? 1. Administer oxygen 2. Assess breath sounds 3. Take vital signs every 30 minutes 4. Return the patient to bed by wheelchair 5. Place the patient in the high-Fowler's position

1. Administer oxygen 4. Return the patient to bed by wheelchair 5. Place the patient in the high-Fowler's position

The wound care nurse in a long-term care facility asks the UAP for assistance. Which task should not be delegated to the UAP? 1. Apply the wound debriding paste to the wound 2. Keep the resident's heels off the surface of the bed 3. Turn the resident at least every 2 hours. 4. Encourage the resident to drink a high-protein shake.

1. Apply the wound debriding paste to the wound Wound debriding formulations are medications, and a UAP cannot administer medications.

A tornado has ripped through a community leaving demolished homes and extensive damage. As a nurse arriving at the site, you find many people who need medical attention, among them, a man walking aimlessly around mumbling to himself. Another neighbor tells you that he is a diabetic. What would be included in your assessment and action? 1. Assess his level of consciousness. If he obeys commands, place a yellow tag on his upper body 2. Diabetics are treated differently. Place a red tag on his upper body and yell for help. 3. Attempt to find diabetic supplies and test his blood sugar immediately 4. Ask him what he has lost

1. Assess his level of consciousness. If he obeys commands, place a yellow tag on his upper body

Professionalism generally refers to an individual's commitment to their occupation. It includes the following (select all that apply) 1. Attitude 2. Knowledge 3. Appearance 4. Conduct 5. Skills

1. Attitude 3. Appearance 4. Conduct

Sonya student nurse is teaching a class on ethics. She includes the following ethical terminology in her lecture. Select all that apply. 1. Beneficence which is the principle of being benefit to others 2. Liberty which is freedom from coercion 3. Justice which is fairness to all 4. autonomy which is ability to make own decisions 5. Non-maleficence which is the principle of doing no harm

1. Beneficence which is the principle of being benefit to others 3. Justice which is fairness to all 4. Autonomy which is ability to make own decisions 5. Non-maleficence which is the principle of doing no harm

The student nurse is attending a lecture on conflict management. After the lecture he tries to remember what strategies were discussed to manage conflict appropriately. He knows this includes: (select all that apply) 1. Best to solve problems by "talking out not acting out" 2. Ground rules have no purpose in conflict management 3. Conflict can be used as an opportunity for solving a problem 4. Conflict if constructive can enhance teamwork and build trust 5. conflict is a negative and unproductive approach for people to vent their feelings

1. Best to solve problems by "talking out not acting out" 3. Conflict can be used as an opportunity for solving a problem 4. Conflict if constructive can enhance teamwork and build trust

The most effective conflict management style: 1. Is collaboration 2. Is competition 3. Is compromise 4. Depends on the situation 5. Depends upon the participants core personality traits.

1. Is collaboration this is considered to be a win-win conflict management style and requires all involved to work together to solve the issue.

Which activity would be considered expected behavior during the refreezing phase of planned change? 1. Developing policies and procedures 2. Working to develop trust 3. Identifying restraining forces 4. Allowing time for people to assimilate the change

1. Developing policies and procedures the change agent is reinforcing new patterns of behavior brought about by the change. Institutionalizing the change by creating new policies and procedures helps to refreeze the system at a new level of equilibrium. Refreezing has occurred when the new way of doing things becomes the new status quo.

When the nurse attempts to administer a medication to a patient, the patient refuses to take the medication because it causes diarrhea. The nurse provides teaching about the medication, but the patient continues to adamantly refuse the medication. What should the nurse do first? 1. Document the patient's refusal to take the medication 2. Notify the practitioner of the patient's refusal to take the medication 3. Discuss with a family member the need for the patient to take the medication 4. Explain again to the patient the consequences of refusing to take the medication

1. Document the patient's refusal to take the medication Withholding the medication and documenting the patient's refusal and why are the appropriate interventions. patient's have a right to refuse care.

Which of the following nursing actions are appropriate if a severe weather alarm is activated? (Select all that apply) 1. Draw all shades and close all drapes as protection against shattering glass. 2. Lower all beds to the lowest position and move beds away from the windows as much as possible 3. Keep doors open to facilitate quick evacuation of clients 4. Get as many ambulatory clients as possible into the hallways 5. Use the elevators to move clients to lower levels 6. Turn the weather radio unit on for severe weather warnings.

1. Draw all shades and close all drapes as protection against shattering glass. 2. Lower all beds to the lowest position and move beds away from the windows as much as possible 4. Get as many ambulatory clients as possible into the hallways 6. Turn the weather radio unit on for severe weather warnings.

Which interventions should the nurse implement for the client diagnosed with hyperthyroidism? (Select all that apply) 1. Establish a supportive and trusting relationship to help the client cope. 2. Assist with exercises involving large muscle groups 3. Instruct the unlicensed assistive personnel (UAP) to apply multiple blankets to the bed 4. Explain that the caregiver should not leave the client alone 5. Place the client in a cool room away from high-traffic areas.

1. Establish a supportive and trusting relationship to help the client cope. 2. Assist with exercises involving large muscle groups 5. Place the client in a cool room away from high-traffic areas. 1 is an intervention the nurse should establish with every client. 2 exercises with large muscles allow the release of nervous tension and restlessness. Tremors can interfere with small muscle coordination. 5 a calm quiet cool room should be provided because increased metabolism causes sleep disturbances and the feeling of being hot.

The main purpose of the American Nurses Association is to: 1. Establish standards of nursing practice 2. Recognize academic achievement in nursing 3. Monitor educational institutions granting degrees in nursing 4. Prepare nurses to become members of the nursing profession

1. Establish standards of nursing practice The ANA has established standards of care standards of professional performance. These standards reflect the values of the nursing profession, provide expectations for nursing practice, facilitate the evaluation of nursing practice, and define the profession's accountability to the public.

In disaster preparedness planning for a bioterrorism event that may involve chemical agents, the nurse should know which of the following? 1. Health care workers will need training regarding antidotes 2. Communicability of the agents will be a big concern 3. Decontamination procedures are only needed for radiological and nuclear terrorism 4. Anthrax is one of the most likely chemical agents to be used as a weapon

1. Health care workers will need training regarding antidotes Public health responsibilities for preparedness planning regarding chemical attacks include developing capabilities for the education of first responders and health care personnel about chemical antidotes.

Nancy Nurse, RN, completes an assessment on Patti Patient and delegates bathing, mobility, and nutrition care to a newly hired certified nurse assistant. Nancy Nurse, RN, is then able to admit another patient to the agency. The principle of delegation that Nancy must remember here is: 1. Implementation of nursing care, including delegated care, remains the responsibility of the nurse. 2. New employees have completed an orientation program to ascertain skill levels 3. Certified nursing assistants are licensed by a national testing agency 4. Skills involved in this scenario are common, and completion can be expected.

1. Implementation of nursing care, including delegated care, remains the responsibility of the nurse. As the delegator you want to make sure you retain accountability and responsibility that the task is completed.

The RN, LPN, and UAP are caring for a group of clients on a surgical unit. Which nursing task should the nurse assign to the LPN? 1. Insert an indwelling urinary catheter before surgery 2. Turn and reposition the client every 2 hours 3. Measure and record the urine in the bedside commode 4. Feed the client who gagged on the food during the last meal

1. Insert an indwelling urinary catheter before surgery The LPN is qualified to perform a sterile procedure , such as inserting an indwellibng catheter before surgery. This is an appropriate assignment.

The RN, LPN and UAP are caring for a group of clients on a surgical unit. Which nursing task should the nurse assign to the LPN? 1. Insert an indwelling urinary catheter before surgery. 2. Turn and reposition the client every 2 hours 3. Measure and record the urine in the bedside commode 4. Feed the client who gagged on the food during the last meal.

1. Insert an indwelling urinary catheter before surgery. The LPN is qualified to perform a sterile procedure, such as inserting an indwelling catheter before surgery. this is an appropriate assignment. No. 2 turning and repositioning a client can be delegated to a UAP. No. 3 emptying a client;s bedside commode and recording the amount of urine can be delegated to a UAP and No. 4 The nurse should feed the client who gagged during the last meal to assess the client's ability to swallow. this client is unstable and cannot be assigned/delegated.

Mr. Jones says to the nurse, " what are the legal forms of advance directives for health care?" You respond that:(select all that apply) 1. Living Will 2. Durable power of attorney for health care decisions (DPAHC) 3. Executor 4. Will 5. Advance Directive

1. Living Will 2. Durable power of attorney for health care decisions (DPAHC) 5. Advance Directive 1,2,5 are all correct as they determine and designate health care related decisions.

Which of the following levels of government should be the first line of defense in the event of an external disaster? 1. Local 2. Regional 3. State 4. Federal

1. Local

The nurse and the UAP are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to delegate? 1. Provide indwelling catheter care to a client on bed rest 2. Evaluate the client's 8 hour intake and output 3. Give a bath to the client who is third-spacing 4. Administer a cation-exchange resin enema

1. Provide indwelling catheter care to a client on bed rest The UAP can clean the perineal area of a client who is on bed rest and who has an indwelling catheter. Because the client is stable, this nursing task could be delegated to the UAP

The nurse is explaining mammography screening to a patient who is reluctant to have the diagnostic test. The nurse understands that this diagnostic test reflects which Level of Prevention? 1. Secondary 2. Tertiary 3. Primary 4. Acute

1. Secondary Screenings are an example of secondary prevention. secondary prevention is associated with early detection, early and quick intervention, health maintenance, and prevention of complications. The levels of prevention identify three levels of prevention to focus on health care activities primary is promotion, secondary is early detection and treatment and tertiary is reducing complications.

Empowerment is an important concept in nursing. Nurses often talk about empowering patients. Empowerment is also important in leadership as it influences: (select all that apply) 1. Social reform 2. competence 3. Productivity 4. coercion 5. collaboration

1. Social reform 2. competence 3. Productivity 5. collaboration

A Registered Nurse witnesses an accident and assists the victim who has a life-threatening injury. To meet the most important standard of acting as a Good Samaritan at the scene of an accident, the nurse should: 1. Stay at the scene until another qualified person takes over 2. Seek consent from the injured party before rendering assistance 3. Implement every possible critical-care intervention necessary to sustain life 4. Insist on helping because a nurse is the best qualified person to provide care

1. Stay at the scene until another qualified person takes over When a nurse renders emergency care, the nurse has an ethical responsibility not to abandon the injured person. The nurse should not leave the scene until the injured person leaves or antoher qualified person assumes responsibility.

The LPN informs the nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement? 1. Tell the LPN to notify the the physician 2. Instruct the LPN to assess the client for abnormal bleeding 3. Obtain a stat electrocardiogram on the client. 4. Take no action because this INR is within the normal range.

1. Tell the LPN to notify the the physician the LPN can contact the physician and give pertinent information. The INR is too high normal between 2 and 3 and the physician should be notified. No. 2 the RN cannot assign assessment to an LPN and No. 3 the INR is elevated but this iwll not affect the client's atrial fib. The client is at risk for abnormal bleeding, not a life-threatening dysrhythmia. No. 4 the normal INR is between 2 and 3 therefore some action should be taken.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report? 1. The 68-year-old client diagnosed with diverticulitis who has a hard abdomen. 2. The 75-year-old client who cannot void after inguinal hernia surgery. 3. The 84-year-old client diagnosed with renal calculi who thinks he passed a stone. 4. The 86-year-old client who refuses to ambulate with the UAP after a lung biopsy

1. The 68-year-old client diagnosed with diverticultiis who has a hard abdomen. The nurse should assess this client first. A hard abdomen may indicated peritonitis, a medical emergency. The signs of peritonitis are a hard, rigid abdomen; tenderness; and fever. No. 2 Clients frequently have diffficulty voiding after inguinal surgery. This is expected. No. 3 The nurse should check on whether the client has passed a stone, but this is a desired outcome and could wait until the lcient with an emergency has been assessed and approprite interventions initiated. No. 4 refusing to ambulate is a problem that can wait until the client with an emergency has been assessed and appropriate interventions initiated.

The nurse is caring for clients on a medical unit. Which laboratory data warrants immediate intervention by the nurse? 1. The PTT of 98 seconds with a control of 36 on a client diagnosed with deep vein thrombosis (DVT) 2. The hemoglobin and hematocrit (h & h) of 10.4/31 for a client diagnosed with a bleeding gastric ulcer 3. The white blood cell (WBC) count of 4800 for a client diagnosed with leukemia 4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN)

1. The PTT of 98 seconds with a control of 36 on a client diagnosed with deep vein thrombosis (DVT) Therapeutic levels for PTT should be 1 1/2 to 2 times the control--that is, 54 to 72 seconds when the control is 36; therefore, this client is at risk for bleeding. The prolonged PTT indicates the client is receiving heparin. The nurse should stop the infusion and follow the facility protocol. No. 2 although this H & H is low it would be expected in a client diagnosed with a bleeding gastric ulcer. No. 3 This WBC count is low but it would be considered good in a client diagnosed with leukemia and No. 4 The nurse should notify the HCP on rounds of laboratory data that is abnormal but not immediately life threatening. The triglyceride level is high, but it will take weeks to months of a healthy heart diet and exercise and possibly medications to lower this level.

For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? 1. Closely assess for nonverbal signs such as grimacing or rocking 2. Obtain baseline behavioral indicators from family members 3. Look at the MAR and chart, to note the time of the last dose and response 4. Give the maximum PRN dose within the minimum time frame for relief.

2. Obtain baseline behavioral indicators from family members Complete information from the family shuold be obtained during the initial ocmprehensive history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.

The nurse has received the shift report. Which client should the nurse assess first? 1. The client diagnosed with a DVT who is complaining of dyspnea and coughing 2. The client diagnosed with gallbladder ulcer disease who refuses to eat the food served. 3. The client diagnosed with pancreatitis who wants the nasogastric tube removed 4. The client diagnosed with osteoarthritis who is complaining of stiff joints.

1. The client diagnosed with a DVT who is complaining of dyspnea and coughing This client is exhibiting signs and symptoms of a potentially fatal complication of DVT--pulmonary embolism. The nurse should assess this client first. No. 2 refusing to eat hospital food should be discussed with the client, but the nurse could ask the unit secretary to have the dietitian see the client. No. 3 clients diagnosed with pancreatitis have nasogasttric tubes to rest the bowel. However, these tubes ar typically uncomfortable. Regardless, the nurse should see this client after the client diagnosed with DVT has been assessed and appropriate interventions initiated. The nurse should discuss the importance of maintaining the tube with the client. No. 4 This is an expected symptom of osteoarthritis. this client does not need to be assessed first.

As part of disaster preparedness planning for a bioterrorism event, the emergency room nurse is checking on the supply of personal protective equipment for the healthcare staff. Knowing that there are several levels of protection, the availability of full face shields, water repellent gowns, and rubber boots would be considered which of the following? 1. The minimum protection needed 2. The preferred protection to have available 3. Components of specialized protection equipment 4. Unnecessary for most responses to a bioterrorism event.

1. The minimum protection needed

Which client should the newborn nurse refer to the hospital ethics committee? 1. The newborn who is anencephalic whose parents want everything done 2. The newborn whose 16-year-old mother wants to place the infant up for adoption. 3. The newborn whose mother is a known cocaine user and is HIV positive 4. The newborn who needs to a unit of blood and the parents are refusing consent

1. The newborn who is anencephalic whose parents want everything done Anencephaly is a congenital abnormality that entails an absence of all or a major part of the brain. The infant has no chance of life outside of a healthcare institution. The healthcare team refers situations to the ethics committee to help resolve dilemmas when caring for clients.

Which of the following actions by a nurse can minimize her chances of being charged with negligence? (Select all that apply) 1. Thoroughly explaining procedures prior to performing them 2. Approaching the client in a caring manner 3. Asking the client if she has any questions about her care 4. Providing care according to the plan of care 5. Documenting assessments in the client's medical record 6. Carrying out the primary care provider's orders without question

1. Thoroughly explaining procedures prior to performing them 2. Approaching the client in a caring manner 3. Asking the client if she has any questions about her care 4. Providing care according to the plan of care 5. Documenting assessments in the client's medical record All but the last action can help the client receive and perceive that she is receiving competent, caring, and thorough client care. If all these criteria are met, the chances of negligence occurring are minimized. It is necessary to questions a primary care provider's order if the nruse deems it could have adverse effects on the cleint or if it is contraindicated secondary to another condition or tgreatment. If the nurse carries out an order that goes against what a reasonable and prudent nurse should know, he could be held liable for implementing the order.

The home health nurse has arranged for a home health aide (HHA) to assist a 79-year-old client diagnosed with Alzheimer's disease. Which interventions should the nurse delegate to the HHA? Choose all that apply. 1. Weigh the client once a week and document the weight on the patient record. 2. Stay with the client twice a week while the significant other goes out to run errands 3. Take and record the client's vital signs 4. Take the client to the bank and store to perform personal business 5. Listen to the client's heart sounds and notify the HCP if abnormal sounds are heard.

1. Weigh the client once a week and document the weight on the patient record. 2. Stay with the client twice a week while the significant other goes out to run errands 3. Take and record the client's vital signs

The plan of care for the diabetic patient includes all of the following interventions. Which intervention could you delegate to the nursing assistant? 1. Check to make sure that the patient's bath water is not too hot 2. Discuss community resources for diabetic outpatient care 3. Instruct the patient to perform daily foot inspections 4. Check the patient's technique for drawing up insulin into a syringe.

1. check to make sure that the patient's bath water is not too hot checking the bath water temperatiure is part of assisting with activities of daily living and is within their scope of practice. discussion of ocmmunity resources and teaching and assessing require a higher level of education and are appropriate to the scope of practice of the LPN or RN

Which task would be most appropriate for the nurse to delegate to the UAP working on a surgical unit? 1. Escort the client to the smoking area outside 2. Obtain vital signs on a newly admitted client. 3. Administer a feeding to the client with a gastrostomy tube. 4. Check the toes of a client who just had a cast application.

2. Obtain vital signs on a newly admitted client. No. 2 The UAp can take vital signs on a newly admitted client. No. 1 the UAP is being paid to help care for the clients not escort them down to the smoking area. No. 3 this client requires assessing the residual to determine if the feeding is appropriate and will be tolerated and No. 4 if the toes are cold and have a capillary refill time of more than 3 seconds or are pale the nurse must make a judgment as to the circulatory status of the foot so this would not be an appropriate task to delegate

The RN is working with a certified nursing assistant (CNA) and a licensed practical nurse (LPN) in providing care to a troup of clients. Which tasks should the nurse assign to the CNA and LPN? 1. CNA to perform simple dressing changes; LPN to assess and care for two non-complex clients. 2. CNA to empty and record urinary catheter bag drainage; LPN to administer oral and intramuscular medications. 3. CNA to assist clients with hygiene; LPN to provide postmortem care and meet with a deceased client's family 4. CNA to take and document vital signs on all clients; LPN to complete the discharge paperwork to be reviewed with two clients.

2. CNA to empty and record urinary catheter bag drainage; LPN to administer oral and intramuscular medications. the scope of practice of the CNA includes measuring and recording intake and output and for the LPN to administer oral and intramuscular medications. A CNA is able in some facilities to perform a simple dressing change, but if the registered nurse changes it the RN would be able to assess the incision. An LPN should not be assessing clients. A CNA is able to assist with hygiene but meeting with the family of a deceased client should be completed by the RN and not the LPN. a CNA is able to take and document vital signs but the RN should be completeing discharge paperwork to be reviewed with the clients. The discharge paperwork often includes a review of the care plan addressing unmet needs of the client.

When the nurse is administering a medication to a confused patient, the patient says, "This pill looks different from the one I had before." What should the nurse do? 1. Ask what the other pill looked like 2. Check the original medication order 3. Explain the purpose of the medication 4. Encourage the patient to take the medication

2. Check the original medication order This is the safest intervention because it goes to the original source of the order.

During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action would be most appropriate for the nurse to implement? 1. Have security escort the reporter off the premises 2. Direct the reporter to the disaster command post 3. Tell the reporter that this is a violation of HIPAA 4. Request the reporter to stay out of the way.

2. Direct the reporter to the disaster command post disaster plans will have a designated disaster plan coordinator. All public information should be routed through this person.

A nursing student observes an incorrect dosage of medication being given to a client receiving electroconvulsive therapy. To implement the ethical principle of veracity, which action would the nursing student take? 1. Keep the information confidential to avoid harm to others 2. Inform the student's instructor and the client's primary nurse, and document the situation. 3. Tell only the client about the incident because the decision about actions would be determined only by the client. 4. Because the client was not harmed, the incident would not need to be reported.

2. Inform the student's instructor and the client's primary nurse, and document the situation. by applying the ethical principle of veracity, the student should tell the truth and report and document the incident. The only limitation to the ethical principle of veracity is when telling the truth would knowingly produce harm. Veracity must be in the context of hospital policy and procedures and within the chain of command.

The client tells the nurse, "I am having surgery on my right knee." However the operative permit is for surgery on the left knee. Which action should the nurse implement first? 1. Notify the operating room team 2. Initiate the time-out procedure 3. Clarify the correct extremity with the client 4. Call the surgeon to discuss the discrepancy

2. Initiate the time-out procedure The joint commission says this is the first intervention to call a time-out which stops the surgery until clarification is obtained. No. 1 the nurse should notify the operating room team, but according to JACHO the first intervention is to call a time-out first, which stops the surgery until clarifiaction is obtained. No. 3 The nurse should idscuss this with the client but should first initiate the time-out procedure. No. 4 Calling the surgeon is a part of the time-out procedure, so the first intervention would be to call the time out.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client states, "The strap was worn just at the very spot where it snapped." The nurse is: 1. Totally and singly responsible for the obvious negligence because of failure to report defective equipment 2. Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client. 3. Exempt from any lawsuit because of the doctrine of respondent superior 4. Exonerated, because only the hospital, as principal employer, is primarily responsible for the quality and maintenance of equipment.

2. Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client. Using a stretcher with worn straps is negligent; this oversight does not reflect the actions of a reasonably prudent nurse.

Place the following phases of the disaster cycle in appropriate order. 1. Emergency phase 2. Non-disaster or inter-disaster phase 3. Impact phase 4. Reconstruction or rehabilitation phase 5. Pre-disaster or warning phase

2. Non-disaster or inter-disaster phase 5. Pre-disaster or warning phase 3. Impact phase 1. Emergency phase 4. Reconstruction or rehabilitation phase

Identify the actions that are examples of slander. Check all that apply. 1. Volunteer telling another volunteer a patient's age 2. Nurse explaining to a patient that another nurse is incompetent 3. Personal care assistant sharing information about a patient with another patient. 4. Unit Manager documenting a nurse's medication error in a performance appraisal 5. Housekeeper who is angry at a nurse erroneously telling another staff member that the nurse uses cocaine

2. Nurse explaining to a patient that another nurse is incompetent 5. Housekeeper who is angry at a nurse erroneously telling another staff memeber that the nurse uses cocaine No. 2 is an example of slander. Slander is a false spoken statement resulting in damage to a person's character or reputation No. 5--This is an example of slander. It is a malacious, false statement that may damage the nurse's reputation.

Who is used as a triage officer during the time of a disaster? 1. Members of the Federal Emergency Management Agency (FEMA) 2. The emergency room physician who directs all care 3. Representatives from the American Red Cross 4. Nurses and other emergency personnel

4. Nurses and other emergency personnel Nurses and other emergency pe3rsonnel are used as triage officers because physicians are administering emergency care to the more critical victims.

There has been a major school bus accident in the community with many injured children seen on the ground. a 10-year-old boy is found lying in the road. His respiratory rate is 10 breaths per minute. He has good distal pulses and groans to painful stimuli. After this quick assessment, what would be your first intervention? 1. Try to find his parents' home phone number in his book bag. 2. Place a red tag on his upper body and yell for help. 3. Place a yellow tag on him since he's breathing and has no apparent wounds 4. Continue to assess his neurological status using the Glasgow Coma Scale.

2. Place a red tag on his upper body and yell for help. Any child who has a respiratory rate of less than 10 or greater than 45 should be tagged with red, indicating immediate care should be given. During a multiple casualty accident, there is not time to perform a complete neurological assessment.

The nurse is talking with a client regarding the main goal of primary intervention. She states that primary prevention is: 1. Aimed at treating symptoms that have already been produced by stressors 2. Prevention of possible symptoms that could be caused by environmental stressors. 3. Seeks to restore the client's system to an optimal state of balance. 4. Is to identify stressors that will disrupt a defensive boundary.

2. Prevention of possible symptoms that could be caused by environmental stressors. primary intervention is to prevent possible symptoms that could be caused by environmental stressors. teaching clients about stress management, giving immunizations, and encouraging aerobic exercise to prevent heart disease are examples of primacy interventions. 1 is a secondary intervention, 3 is a tertiary intervention and 4 is a stressor.

In preparing a client for a colonoscopy procedure, which task is most suitable to delegate to the nursing assistant? 1. Explain the need for clear liquids 1-3 days prior to the procedure 2. Reinforce NPO status 8 hours prior to procedure 3. Administer laxative 1-3 days prior to procedure 4. Administer an enema the night before the procedure

2. Reinforce NPO status 8 hours prior to procedure the nursing assistant can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the nursing assistant can administer the enema; however special training is required and policies may vary between instituitions. Meidcation administration should be perfromed by licensed personnel.

The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first? 1. Consult with the hospital's attorney. 2. Review the client's chart 3. Purchase personal liability insurance 4. Discuss the case with the supervisor

2. Review the client's chart

The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first? 1. Consult with the hospital's attorney 2. Review the client's chart 3. Purchase personal liability insurance 4. Discuss the case with the supervisor

2. Review the client's chart The nurse should be familiar with the chart and the situation so that details can be remembered. this should be the nurse's first action.

Which determines the scope of practice for a registered nurse employed in the field of nursing? 1. National League of Nursing (NLN) 2. State Law which may vary from state to state 4. American Nursing Association (ANA) 5. Joint Commission for Health Care Operation (JCHCO)

2. State Law which may vary from state to state

The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the new graduate nurse? 1. The client who has received 3 units of packed red blood cells (RBC's) 2. The client going for an esophagogastroduodenoscopy (EGD) in the morning 3. The client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome. 4. The client who has just returned from a cardiac catheterization.

2. The client going for an esophagogastroduodenoscopy (EGD) in the morning No. 2 this client is being prepared for a test in the morning and is the least acute of the clients listed. The new graduate should be assigned to this client. No. 1 this client is unstable and should not be assigned to a new graduate nurse. No. 3 this client has a complication of diabetes mellitus type 2; a more experienced nurse should be assigned to this client. No. 4 a client returning from a cardiac catheterization has potential for life-threatening complications such as hemorrhaging and should be assigned to a more experienced nurse.

the nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with pneumonia who has bilateral crackles. 2. The client on strict bed rest who is complaining of calf pain. 3. The client who complains of low back pain when sitting in a chair. 4. The client who is upset because the food is cold all the time.

2. The client on strict bed rest who is complaining of calf pain. No. 2 is top priority as this client with calf pain could be experiencing deep vein thrombosis (DVT) a complication of immobility, which may be fatal if a pulmonary embolism occurs; therefore this client should e assessed first. No. 1 a typical sign of pneumonia is bilateral crackles; therefore this client would not need to be seen first. No. 3 the client experiencing low back pain when sitting in a chair should be assessed but not prior to the client with suspected DVT. and No. 4 the nurse should address the client's concern about he food, but it is not priority over a physiologic problem.

Which change identified by the nurse will most affect health-care delivery in the United States in the future? 1. Less emphasis will be placed on prolonging life 2. The proportion of older adults in society will increase 3. More people will seek health care in an acute care setting. 4. Genetic counseling will dramatically decrease the number of ill infants born.

2. The proportion of older adults in society will increase the percentage of older adults in the US is expected to increase to 22% by the year 2030. Fourteen percent of the 22% will be people over the age of 85

Nancy Nurse is a new graduate and she asks her friend who works at a Magnet Hospital what makes her place of employment so much better than other places. Her friend responds: 1. It is a leader driven operation 2. As a practicing nurse I have a high level of autonomy in my decision making 3. It is a vertical organization structure 4. Their are really no differences between the hospital that I work at and the other hospitals in the area.

2. as a practicing nurse I have a high level of autonomy in my decision making This was discussed in the lecture and magnet status is a participative, horizontal organization structure giving nurses more autonomy in practice and decision making. Employees are encouraged to seek opportunities for career development and high quality care is delivered to clients. Also nurses are more satisfied with their jobs and turn over is much lower in a magnet hospital.

The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first? 1. Reinsert the nasogastric tube for the client who has pulled it out. 2. Complete the preoperative checklist for the client scheduled for surgery 3. Instruct the client who is being discharged home about colostomy care 4. Change the client's surgical dressing that has a 20 cm area of drainage.

2. complete the preoperative checklist for the client scheduled for surgery The client scheduled for surgery is priority and must be ready when the OR calls; therefore, completing the preoperative checklist is the first task the nurse should implement. The preoperative checklist ensures the client's safety. No. 1 The nasogastric tube should be replaced, but this task will require more time and obtaining new equipment; therefore it should not be done first. No. 3 The client being discharged can wait unitl the safety needs of the client going to surgery have been addressed. No. This is a minimal to moderate amount of drainage, which requires a dressing change, but not prior to making sure the client going to surgery is ready.

The differences in practice between a BSN and a ADN prepared nurse were identified by Chief nursing officers as: 1. professional boundaries and behaviors 2. critical thinking and leadership 3. time management and prioritization 4. skill ability and application

2. critical thinking and leadership

In the Institute of Medicine report they recommend that by the year 2020 what percentage of the nursing work force should be BSN prepared at the bedside? 1. 40% 2. 60% 3. 80% 4. 50%

3. 80%

According to the American Red Cross, a major disaster is classified as which of the following? 1. A disaster that affects more than one family, occurs within the jurisdiction of one American Red Cross chapter, and requires limited human and material resources. 2. A disaster that affects multiple families in a single state and may require disaster help from more than one Red Cross chapter. 3. A disaster that requires the help of multiple Red Cross units, affects more than a single state, and may be expected to be declared an emergency by the President of the United States 4. A disaster that requires full or partial implementation of the Federal Response Plan. This disaster exceeds the ability of the state and local government capabilities to meet the needs of the situation.

3. A disaster that requires the help of multiple Red Cross units, affects more than a single state, and may be expected to be declared an emergency by the President of the United States This is the definition of the scope of a major disaster. #1 is a local disaster, #2 is a state disaster and #4 is the definition of a Presidentially Declared Disaster.

The nurse is administrating medications for clients on a medical unit. Which medications should the nurse administer first? 1. The narcotic pain medication to a client complaining that his pain is an "8" 2. A loop diuretic to a client diagnosed with heart failure who has 3+ pitting edema 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis 4. An antacid to a client with pyrosis who has called several times over the intercom.

3. An anticholinesterase medication to a client diagnosed with myasthenia gravis Anticholinesterase medications administered for myasthenia gravis must be administered on time to perserve muscle functioning, especially the funtioning of the muscles of the upper respiratory tract. This is the priority medication. No. 1 A pain medication is important to administer in a timnely manner, but its administration is not priority over a medication that must be administered on time to prevent respiratory complications. No. 2 For a client experiencing expected symptoms of a disease, such as pitting edema, administration of a loop diuretic has a 30-minute leeway--that is, it can be adminsitred 30 minutes before to 30 minutes after the scheduled dosing time. No. 4 clients who have called for medications should be attended to, but this client would not receive an antacid for heartburn before the client diagnosed with myasthenia gravis or the client in pain.

The charge nurse in the ICU is notified of a bus accident with multiple injuries, and clients are being brought to the ED. The hospital is implementing the disaster policy. Which intervention should the nurse implement first? 1. Determine which clients could be transferred out of the ICU 2. Call any off-duty nurses to notify them to come in to work. 3. Assess the staffing to determine which staff could be sent to the ED 4. Request all visitors to leave the hospital as soon as possible.

3. Assess the staffing to determine which staff could be sent to the ED Most disaster policies require one nurse to be sent immediately from each area; therefore, this intervention should be implemented first. The charge must determine which staff nurse would be most helpful in the ED without compromising the staffing in the ICU. The sending of an nurse to the ED is first then you would look at available beds in the ICU and the possibility of transferring people out. You would need to do this but it isn't the first intervention. And you wouldn't ask people to leave that isn't protocol.

The nurse and the UAP (unlicensed assistive personnel) are caring for clients on a rehabilitation unit. Which nursing task is most appropriate for the nurse to delegate to the UAP? 1. Flush the triple-lumen lines on a central venous catheter 2. Demonstrate for the client how to ambulate with a walker 3. Assist with bowel training by escorting the client to the bathroom 4. Apply corticosteroid cream to the client with allergic dermatitis

3. Assist with bowel training by escorting the client to the bathroom The UAP can assist the client to the bathroom as part of the bowel training; the nurse is responsible for the training but the nurse can delegate this task. The triple-lumen lines should be flushed with 100 units/mL of heparin solution, and this task should not be delegated to a UAP. 2. this is teaching and the nurse should not delegate teaching to the client 4. Corticosteroid cream is a medication and the nurse cannot delegate medication to a UAP.

A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse looks up the policy and procedure for the institution to review how to insert it. The level of critical thinking the nurse is using is: 1. Commitment 2. Scientific method 3. Basic critical thinking 4. Complex critical thinking

3. Basic critical thinking

The male client recovering from an acute deep vein thrombosis (DVT) is transferred to the rehabilitation unit. The client is complaining of bleeding when brushing his teeth. The nurse reviews the client's medication administration record (MAR). Which intervention should the nurse implement first? 1. Prepare to administer AquaMephyton (vitamin K) 2. Determine whether the client is using a soft bristle toothbrush 3. Check the client's apical pulse and blood pressure 4. Request the laboratory to draw a stat INR.

4. Request the laboratory to draw a stat INR. The nurse should first check the client's INR to determine whether the bleeding is secondary to an elevated INR level above 3

The client receiving dialysis is complaining of being dizzy and light-headed. Which priority intervention should the nurse implement? 1. Place the client in reverse Trendelenburg position. 2. Decrease the volume of blood being removed from the client 3. Bolus the client 300 mL of 0.9% saline solution. 4. Notify the healthcare provider as soon as possible.

3. Bolus the client 300 mL of 0.9% saline solution. Normal saline infusion increases the amount of volume in the bloodstream, which will decrease the client's lightheadedness and dizziness. Reverse trendelenburg has the nurse elevating the clients chair, decreasing the volume of blood being removed is an appropriate intervention, but it will not help the client's dizziness and lightheadedness as fast as will infusing normal saline. Hypotension is an expected occurrence in clients receiving dialysis; therefore the physician doesn't need to be notified.

An RN is working with an LPN and a UAP to care for a group of clients. Which nursing task should not be delegated or assigned? 1. The routine oral medications for the clients 2. The bed baths and oral care 3. Evaluating the client's progress 4. Transporting a client to dialysis

3. Evaluating the client's progress The RN cannot delegate or assign tasks that require nursing judgment, such as evaluating a client's progress. No. 1 The LPN may be assigned to administer the routine oral medications to the clients. No. 2 bed baths and oral care can be performed by the UAP and No. 4 the uap can transport a client to dialysis.

The client diagnosed with renal calculi is 1 hour post-procedure lithotripsy. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) 1. Tell the UAP to check the amount, color, and consistency of the client's urine output. 2. Request the UAP to transcribe the client's healthcare provider's orders 3. Instruct the UAP to strain the client's urine and place any sediment in a sterile container. 4. Ask the UAP to take the client's post-procedural vital signs.

3. Instruct the UAP to strain the client's urine and place any sediment in a sterile container. The UAP can strain the client's urine. This task does not require judgment or evaluation. Any sediment should be placed in a sterile container and sent to the laboratory for analysis. The kidney is highly vascular. Hemorrhaging and the resulting shock are potential complications of lithotripsy so the nurse should not delegate vital signs post-procedure

Which nursing theorist developed the novice to expert continuum? 1. Jean Watson 2. Lydia E. Hall 3. Patricia Benner 4. Sister Calista Roy

3. Patricia Benner

Theorist Jean Watson Philosophy and Science of Caring has 10 Carative Factors that include which of the following concepts 1. Meaning 2. Rhythmicity 3. Person 4. Patiency

3. Person

A multiple car accident has occurred on the local expressway. Among the many casualties is an adult male, found trapped under the car. Upon examination, you find that he is apneic, but has a weak pulse at 120 beats per minute. After repositioning his upper airway, he remains apneic. As a nurse in the field, how do you proceed? 1. Start CPR and continue until EMS arrives 2. Place a red tag on the man's upper body and yell for help 3. Place a black tag on the man's upper body and attempt to help the next accident victim 4. Reposition his upper airway again before assessing his respirations.

3. Place a black tag on the man's upper body and attempt to help the next accident victim When assessing an apneic adult casualty in a disaster situation, attempt to reposition the upper airway once. If the person still does not breathe, a black tag (dying or death) should be placed on the upper body and the rescuer should attempt to aid the next person.

The community health nurse is triaging victims at the scene of a building collapse. Which intervention should the nurse implement first? 1. Discuss the disaster situation with the media 2. Write the client's name clearly in the disaster log 3. Place disaster tags securely on the victims 4. Identify an area for family members to wait

3. Place disaster tags securely on the victims Client tracking is a critical component of casualty management. Disaster tags which include name, address, age location, description of injuries and treatments or medications administered, must be securely attached to the client. A spokesperson should address the media away from the victim care area as soon as possible. You should record the tag and client's name but you need to tag first. family and friends need to be cared for but that isn't the top priority.

The nurse administers an incorrect dose of a medication to a patient. The nurse understands that the primary purpose of documenting this event in an Incident Report is to: 1. Record the event for further litigation 2. Provide a basis for designing new policies 3. Prevent similar situations from happening again 4. Ensure accountability for the cause of the accident.

3. Prevent similar situations from happening again Risk management committees use statistical data about accidents and incidents to identify patterns of risk and prevent future accidents and incidents.

The charge nurse in a large outpatient clinic notices the staff members are arguing and irritable with one other and the atmosphere has been very tense for the past week. Which action should the charge nurse take? 1. Wait for another week to see whether the situation resolves itself. 2. Write a memo telling all staff members to stop arguing 3. Schedule a meeting with the staff to discuss the situation 4. Tell the staff to stop arguing or they will be terminated.

3. Schedule a meeting with the staff to discuss the situation The charge nurse should call a meeting and attempt to determine what is causing the staff's behavior and the tense atmosphere. The charge nurse could then problem-solve, with the goal being to have a more relaxed atmosphere in which to work. the charge nurse must address this situation because it has been going on for more than a week. Writing a memo does nothing to discover the cause of the tense atmosphere and the last statement is threatening which is not an appropriate way to resolve a staff problem.

The hospital has declared a major disaster. Which action should the charge nurse of the medical unit implement first? 1. Make rounds with the discharge officer 2. Instruct the staff in the disaster plan 3. Send one nurse to the disaster command post 4. Maintain the functioning of the unit

3. Send one nurse to the disaster command post The charge nurse must send a qaualified nurse to the command post to assume duties during the disastger. This is the first intervention. No. 1 rounds with the discharge officer will be ocmpleted when the discharge officer gets to the charge nurses's unit. Before this happens, the charge nurse must make a list of possible discharges. No. 2--The staff may need to be reminded of the specific duties during the disaster, but this is not the first intervention. No. 4 The charge nurse is responsible to see that all clients on the unit are receiving care. This is not the first responsibility, but it is an ongoing one.

The nurse and a UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places the gait belt around the client's waist prior to ambulating 2. The assistant places the client on the abdomen with the client's had to the side 3. The assistant places her hand under the client's right axilla to help the client move up in bed. 4. The assistant praises the client for attempting to perform activities of daily living independently.

3. The assistant places her hand under the client's right axilla to help the client move up in bed. No. 3 this action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client's back or using a lift sheet. No. 1 placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. No. 2 placing the client in a prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures; therefore this would not require the nurse to intervene. No. 4 the client should be encouraged and praised for attempting to perform any activities independently, such as combing hair or brushing teeth.

Ms. Kathy is making rounds on the unit. Which client should Ms. Kathy assess first? 1. The client diagnosed with peptic ulcer disease who is receiving blood and has a hemoglobin of 10.1 and hematocrit 35. 2. The client diagnosed with ulcerative colitis who has had 10 loose stools and has a potassium level of 3.5 mEq/L 3. The client who is 1 day post-op abdominal surgery with a hard, rigid abdomen and elevated temperature 4. The client diagnosed with acute diverticulitis whose nasogastric tube is draining green bile

3. The client who is 1 day post-op abdominal surgery with a hard, rigid abdomen and elevated temperature A hard rigid abdomen and elevated temperature is indicative of peritonitis, which is an acute postoperative complication of abdominal surgery and requires immediate intervention. Ms. Kathy should assess this client first.

The charge nurse is making assignments for the surgical unit. Which client should be assigned to the new graduate nurse? 1. The client who has a chest tube for a hemothorax that is draining bright red blood 2. The client who is 1 day postoperative pneumonectomy with a temperature of 102.2 degrees F. 3. The client with pneumonia who has bilateral crackles and a productive cough 4. The client who has a deep vein thrombosis and is complaining of chest pain.

3. The client with pneumonia who has bilateral crackles and a productive cough The client diagnosed with pneumonia would be expected to have bilateral crackles and a productive cough; therefore this client should be assigned to the new graduate nurse. Bleeding may lead to hypovolemia; elevated temperature indicates infection; and chest pain may be pulmonary embolus clients with these problems should be assigned to a more experienced nurse.

Which of the following is an important assumption to make about change? 1. A positive change represents a gain for everyone affected by the change 2. The fewer the people involved in the process, the more likely the change will be accepted 3. The shorter the gap between change initiator and decision maker the more likely the change will be implemented 4. When a series of changes is desired, it is more efficient to implement them all at once

3. The shorter the gap between change initiator and decision maker the more likely the change will be implemented organizations that have many levels of hierarchy between the initiator of change and the ultimate decision makers may have difficulty with implementing change. The shorter the distance the change proposal must travel from the initiator to the decision maker, the greater the likelihood that the change will be accepted. Conversely, the greater the distance, the more likely resistance will occur.

You are taking histories from several clients who report vertigo. Which client report concerns you the most? 1. Vertigo with hearing loss 2. Episodic vertigo 3. Vertigo without hearing loss 4. "Merry go round" vertigo

3. Vertigo without hearing loss Vertigo without hearing loss should be further assessed for nonvestibular causes, such as cardiovascular or metabolic. The other options are more asociated with inner ear or labyrinthine causes.

An example of role conflict is: 1. When the director of respiratory care and the nursing director of the ICU both want to hire a new employee in their discipline to work the ICU 2. When the director of respiratory care believes she does not receive as many resources as the nursing director of the ICU 3. When two secretaries are hired to help with excess work load but the job expectations for each of them is not clear. 4. When line managers believe that support staff use their technical knowledge to intrude on the line manger's legitimate authority.

3. When two secretaries are hired to help with excess work load but the job expectations for each of them is not clear. role conflict occurs when there is inconsistency or misunderstanding about the way a job should be performed.

The nurse is caring for clients on a medical unit. Which intervention should the nurse implement first? 1. Change the leg wound dressing for a client who has ambulated in the hall 2. Discuss the correct method of obtaining a blood glucose level with the unlicensed assistive personnel (UAP)_ 3. Check on the male client who called the desk to say he has just vomited 4. Place a call to the extended care facility to give the report on a discharged client.

3. check on the male client who called the desk to say he has just vomited

The physician asks the nurse to witness an informed consent. The nurse understands that a patient who is unable to give an informed consent for surgery is a: 1. 16-year-old boy who is married 2. 35-year-old woman who is depressed 3. 50-year-old woman who does not speak English 4. 65-year-old man who has received a narcotic for pain

4. 65-year-old man who has received a narcotic for pain Narcotics depress the central nervous system including decision-making abilities. This person is considered functionally incompetent. A minor who is married, pregnant, parents, members of the military or emancipated are able to give informed consent.

The primary difference between effective leaders and managers is that managers have: 1. Vision 2. Charisma 3. Confidence 4. Responsibility

4. Responsibility Managers not leaders have responsibility. Leaders can be formal or informal. Informal leaders are not assigned to direct others. They are viewed as leaders by the members of the group because of their experience, vision, charisma, confidence, expertise, or age.

The nurse is preparing to administer medications. Which medication should the nurse administer first? 1. Digoxin (Lanoxin), a cardiac glycoside, due at 0900 2. Furosemide (lasix), a loop diuretic, due at 0800 3. Propoxyphene (Darvon), an analgesic, due in 2 hours 4. Acetaminophen (tylenol), an analgesic, due in 5 minutes

4. Acetaminophen (tylenol), an analgesic, due in 5 minutes No. 4 tylenol is administered for mild to moderate pain. by the time the nurse obtains the medication and performs all of the steps to administer a medication correctly, it will be time for the client to receive the Tylenol. This medication should be administered first. No. 1 Digoxin can be administered later because it is a routine medication. No. 2 lasix can be administered within the 1-hour leeway (30 minutes before and after) it does not need to be administered first. No. 3 Darvon is not due yet; the nurse should assess the client and determine whether nonpharmacologic interventions to relieve pain can be implemented, but this medication cannot be adminstered for 2 hours.

The student nurse knows that when dealing with a conflict situation how you handle it can be affected by: 1. Your value system 2. Your past experiences 3. The meaning you attach to it 4. All of the above 5. A and B

4. All of the above

A nursing assistant's (NA) job responsibilities include totaling the intake and output (I & O)records for clients at the end of an 8-hour shift. Near the end of the shift, a licensed practice nurse (LPN) reports to the registered nurse (RN) that a new NA on the unit has not completed the task. What is the RN's best action? 1. Ask the LPN to complete this task because the information is needed to give report 2. Remind the NA that the task needs to be completed as quickly as possible 3. Notify the Charge nurse that the NA needs additional orientation on job responsibilities 4. Ask the NA what instruction was given on job responsibilities and ask the NA to state how to total I & O records.

4. Ask the NA what instruction was given on job responsibilities and ask the NA to state how to total I & O records. Delegation of assigned tasks includes determining the delegate's knowledge and ability to perform the task correctly. Asking what instruction was given may also clarify what the NA was told and what the RN perceives to be the task;. It may be that he RN or LPN must five the NA the appropriate forms to be completed after recording the amount for intravenous infusions. Delegation of the NA assigned job responsibilities is inappropriate and can create tension between team members. Reminding the NA may be insufficient if the NA does not know how to total I & O records. Notifying the charge nurse may be premature. Additional information is needed regarding the reason the NA is not performing the task.

The nurse is caring for a male client diagnosed with lung cancer who has a Do Not Resuscitate (DNR) order and has Cheyne-Stokes respirations. The client's wife is at the bedside. Which intervention should the nurse implement first? 1. Notify the nurse's desk of the impending death. 2. Remain quietly at the client's bedside 3. Make the client as comfortable as possible 4. Ask the wife if she would like to stay at the bedside

4. Ask the wife if she would like to stay at the bedside The nurse should first determine if the wife wants to be at her husband's bedside when he dies. Then the nurse should make the client comfortable, remain at the bedside and notify the nurse's desk so that another nurse can care for nurses clients until the client dies.

The right to determine one's own destiny is to autonomy as the duty to benefit or promote the good of others is to: 1. Non-maleficence 2. Justice 3. Veracity 4. Beneficence

4. Beneficence Beneficence is the duty to benefit or promote the good of others.

When considering leadership styles, an "autocratic" leader is to authoritarian" as a "democratic" leader is to: 1. Directive 2. Permissive 3. Oppressive 4. Consultative

4. Consultative consultative is most closely related to the democratic leadership style. Democratic leaders encourage discussion and decision making within the group. The leader facilitates the work of the group by making suggestions, offering constructive criticism, and providing information.

According to the Joint Commission on Accreditation of Healthcare Organizations, all hospitals must perform which of the following tasks? 1. Develop a disaster plan and send it to all nurse managers in the building 2. Develop a disaster plan and hold a disaster drill twice each year. 3. Select a disaster representative from the emergency room department who is responsible for all internal disaster activities. 4. Develop a disaster plan, hold disaster drills twice a year, and regularly evaluate these plans and activities.

4. Develop a disaster plan, hold disaster drills twice a year, and regularly evaluate these plans and activities. Hospital disaster plans should be developed for both internal and external disasters. In order for the hospital to be prepared, these plans should be practiced at least twice per year and evaluated for accuracy and efficiency.

When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. Which is an appropriate response? 1. Negligence 2. Malpractice 3. Breach of duty 4. False imprisonment

4. False imprisonment

Which nursing theorist is considered to be the founder of nursing theory. 1. Fay Abdella 2. Dorothy Johnson 3. Virginia Henderson 4. Florence Nightengale

4. Florence Nightengale

The patient's diet order is "clear liquids to regular as tolerated." When the nurse progresses the diet to full liquid, the nurse is working: 1. Dependently 2. Independently 3. Collaboratively 4. Interdependently

4. Interdependently

Two hours after admitting a client to a post-surgical unit following a nephrectomy, the client states feeling nauseated. A nurse notes minimal drainage from the nasogastric (NG) tube. Which action should the nurse take first? 1. Notify the physician 2. Administer an antiemetic medication listed on the client's medication record 3. Pull the NG tube out about an inch to release it suctioning against the wall of the stomach. 4. Irrigate the NG and check to see if the fluid returns to the drainage-collection container.

4. Irrigate the NG and check to see if the fluid returns to the drainage-collection container. Nausea and minimal returns from the NG tube suggest possible occlusion of the tube. The tube should be irrigated per agency policy or physician's order, especially if the surgical area involved the gastrointestinal system. It is unnecessary to call the physician as the first action. nurses are responsible for maintaining the patency of the NG tube. administering an antiemetic is important for nausea but the functioning NG tube should relieve this by decompressing the stomach and wouldn't be the first action. You wouldn't pull the tube out unless it was determined that it was intestinal contents and not gastric contents.

Which factor is unique to malpractice when comparing negligence and malpractice? 1. The action did not meet standards of care 2. The inappropriate care is an act of commission 3. There is harm to the patient as a result of the care 4. There is a contractual relationship between the nurse and patient

4. There is a contractual relationship between the nurse and patient Only malpractice is misconduct performed in professional practice; where there is a contractual relationship between the patient and nurse, which results in harm to the patient.

As a member of a volunteer disaster medical assistance team, the nurse would be expected to 1. triage casualties of a tornado that hit the local community. 2. assist with implementing the hospital's emergency response plan 3. train citizens of communities how to respond to mass casualty incidents 4. deploy to local or other communities with disasters to provide medical assistance.

4. deploy to local or other communities with disasters to provide medical assistance. Disaster medical assistance teams are composed of members with health or medical situations. Triage is performed by first responders such as police and designated emergency medical personnel. The hospital's emergency response plan is a specific plan that addresses how personnel and resources will be used in case of a disaster, and community emergency response teams provide training to communities in general to respond to disasters.

Politics is the process of negotiation or influencing of allocation of scare resources. In the workplace the number one priority issue is: 1. Visiting hours 2. identification and security procedures 3. nursing clinical ladder program 4. staffing per patient ratio

4. staffing per patient ratio

A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of: 1. a code blue alert 2. a disaster medical assistance team 3. the local police and fire departments 4. the hospital's emergency response plan.

4. the hospital's emergency response plan. 4 is letting the hospital know that they will need to activate their plan to help care for the 125 workers that are having problems from the chemical explosion.