ATI Leadership

A charge nurse is talking with a staff nurse following a workshop on advance directives. Which of the following statements by the staff nurse demonstrates understanding of advance directives?

"A family member of a client can have the living will overturned in some cases."

An assistive personnel (AP) tells the charge nurse that it is unfair that she has to take care of all the clients who are incontinent. Which of the following responses by the charge nurse is appropriate?

"I delegate tasks to personnel based on their job descriptions."

A nurse in a mental health clinic is interviewing a client who has a history of substance use disorder. The client reports his experiences from a previous voluntary hospitalization. Which of the following reported experiences by the client constitutes assault? A. "I was threatened with a shot when I refused to take an oral medication that I knew would make me groggy." B. "I was held down against my will and administered a shot." C. "I was told I had to stay in the facility despite my request to leave." D. "I was exposed as a substance abuser to other clients in a group session."

"I was threatened with a shot when I refused to take an oral medication that I knew would make me groggy." Threatening to medicate clients against their wishes is assault. The tort of assault occurs when a person puts another in fear of nonconsensual contact. Incorrect Answers: B. Performing any procedure on a client without informed consent is battery, not assault. The tort of battery occurs when there is nonconsensual contact with one's person. C. Not allowing clients to leave a health care facility despite their wishes is false imprisonment, not assault. Mental health clients who admit themselves voluntarily to a psychiatric facility retain the right to sign themselves out of the facility. D. Sharing information with others not directly involved in the client's care is a violation of the client's confidentiality, not assault. //

A nurse is caring for a client who asks for information about advance directives. Which of the following is an appropriate response by the nurse?

"Your advance directives will take effect when you are unable to make health care decisions."

A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse?

A client who had a right above-the-knee amputation 24 hr ago

A nurse is receiving change-of-shift report at the start of the shift. Which of the following clients should the nurse assess first?

A client who had abdominal surgery 6 hr ago and has a heart rate of 120/min for the last 2 hr When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority finding is an elevated heart rate following surgery; therefore, the nurse should assess this client first

A charge nurse is planning client care assignments for the unit. Which of the following clients should the nurse assign to a licensed practical nurse (LPN)?

A client who has Crohn's disease and requires an enteral feeding

A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse?

A student nurse is photocopying his assigned client's diagnostic test results.

A nurse is talking with a family member who is unhappy about the care his mother is receiving. Which of the following responses should nurse make? A. "Can you give me a specific example of care that caused dissatisfaction?" B. "Your mother has a lot of complex medical conditions." C. "We'll talk later when you have calmed down." D. "We're very busy with all the clients on this unit."

A. "Can you give me a specific example of care that caused dissatisfaction?" Requesting an example of a specific event can allow the nurse to view the family member's comments objectively and address his concerns. Incorrect Answers:B. This response stereotypes the client's medical condition and does not show concern for the family member's complaint. C. This response is rejecting and passing judgment on the family member's complaints and does not address his concern. D. This response is defensive and does not address the family member's concern. /

A nurse is caring for a client who received a sedative-hypnotic medication at bedtime. The client gets out of bed and falls, sustaining a laceration that requires suturing. Which of the following statements should be included as part of the nurse's documentation in the client's chart? A. "Client found sitting on floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified." B. "Client found sitting on floor with blood running down face. Side rails had not been raised by assistive personnel when client was placed in bed." C. "Client fell due to confusion caused by sleeping medication." D. "Client got out of bed and fell, despite being told to call for assistance when ambulating."

A. "Client found sitting on floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified." This statement is appropriate to include in the documentation. It presents objective facts and assessments related to this event. The nurse should also include vital signs, further assessments, the name of the provider notified, treatments or procedures that were done per the provider's prescription, and the client's response. Incorrect Answers: B. This statement is not appropriate to include in the documentation because it includes a nondescript comment that is open to interpretation. Blame is also placed on the assistive personnel for not putting up the side rails. C. This statement is not appropriate to include in the documentation because it draws a conclusion about why the client fell. Although sedative-hypnotic medications can cause confusion, it is inappropriate to assume that the medication caused the fall. D. This statement is not appropriate to include in the documentation because it places blame on the client. /

A nurse is caring for a male client who is scheduled for a procedure. The client's son asks the nurse what medication is being given to the client. Which of the following responses should the nurse provide? A. "I am sorry, but you'll need to ask your father for that information." B. "Your father was given lorazepam to treat anxiety." C. "You will need to ask the charge nurse for that information." D. "Don't worry. We will give your father all pertinent information before discharge."

A. "I am sorry, but you'll need to ask your father for that information." The nurse must keep the client's personal health information confidential. It is up to the client to share confidential information with his son. Incorrect Answers: B. Telling the client's son about his medication without the client's permission is a breach of confidentiality. C. The charge nurse would also need permission from the client to give information to the son. D. This statement does not answer the son's question and dismisses his concerns. //

A nurse manager believes that a nurse is taking breaks that are too frequent and lengthy. Which assertive statement should the charge nurse use to initiate a discussion of the issue? A. "I understand you are allowed to take scheduled breaks during each shift, but you are taking more than the number allocated. Let's set a time when we can discuss this behavior." B. "You are taking more breaks during each shift than hospital policy allows. You will need to take only the number of breaks specified and ensure you are back on time." C. "You have been taking too many breaks during each shift and do not return on time after your break. I will have to make a formal note about this issue that will be reflected on your next performance appraisal." D. "Why do you take so many breaks? Are you aware there is a policy that designates how many breaks you can take?"

A. "I understand you are allowed to take scheduled breaks during each shift, but you are taking more than the number allocated. Let's set a time when we can discuss this behavior." Assertive communication uses "I" statements that describe the person's observations and feelings. It allows the person being confronted to respond to the issue with his/her own perceptions and feelings instead of feeling verbally assaulted. Subsequently, a verbal discourse can follow that allows an open discussion of the issue. Incorrect Answers: B. This approach conveys an attitude of superiority. It is likely to be seen as authoritative and may cause the coworker to become angry and resentful. C. This statement could be perceived as patronizing, and its close-ended structure does not give the nurse the opportunity to provide any response. A threat is also made in regard to the nurse's performance appraisal in an attempt to coerce the nurse into changing the behavior. D. This statement includes a question that asks for an explanation of the behavior. It implies that the nurse is exhibiting unsatisfactory behavior, which might elicit an unproductive, defensive response by the nurse. This approach also asks the nurse to admit either knowing or not knowing about the policy, testing his/her willingness to admit to improper behavior. //

A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client states, "I don't think I can go through with the surgery after all." Which of the following responses should the nurse provide? A. "I will let the surgeon know about your decision." B. "I recommend that you have the surgery so you don't require as much chemotherapy." C. "If you don't have the surgery, you will likely die from breast cancer." D. "If you are worried about your body image, that will pass in time."

A. "I will let the surgeon know about your decision." The nurse should notify the client's surgeon about her decision regarding the procedure. It is the responsibility of the nurse to be the client's advocate and respect the client's wishes. The client has the right to refuse or change her mind at any time regarding the treatment offered. Incorrect Answers: B. This response provides a personal opinion from the nurse and is outside the scope of practice for a nurse. The nurse should allow the client to make her own decision regarding the procedure and respect the client's wishes. C. This response provides false information from the nurse and is not a professional opinion. D. This response provides false reassurance and assumes how the client feels. /

A nurse is transporting a client to the surgical suite for a procedure. The client tells the nurse he no longer wants to have the surgery. Which of the following responses should the nurse make? A. "Let me call your surgeon while you tell me about your concerns." B. "You should talk to your family before you make this decision." C. "I'll ask your surgeon to speak to you as soon as you are in the surgical suite." D. "Everything will be fine. The operation will be over soon, and you will be glad you had it done."

A. "Let me call your surgeon while you tell me about your concerns." The client has the right to refuse treatment. Speaking with the nurse and the provider about concerns or questions could relieve anxieties and allow the client to continue with the procedure. Consent may be withdrawn after being given. It is the nurse's responsibility to notify the surgeon if the client verbalizes a desire to stop or delay a medical procedure or treatment. Incorrect Answers: B. The nurse should contact the surgeon and address the client's concerns. C. The nurse should contact the surgeon immediately and address the client's concerns. D. The client has the right to refuse the procedure. The nurse should contact the surgeon and address the client's concerns. /

A nurse is providing teaching to a client about organ donation. Which of the following statements by the client indicates an understanding of the teaching? A. "People age 18 and over have the right to decide to make an organ donation." B. "I have to make organ donation a provision in my will." C. "Once I decide to donate, I cannot change that decision." D. "A family member has to serve as a witness for me to be an organ donor."

A. "People age 18 and over have the right to decide to make an organ donation." Under the Uniform Anatomical Gift Act, individuals must be at least 18 years or older to make an anatomical gift. Incorrect Answers: B. Under the Uniform Anatomical Gift Act, organ donation can be a provision in a will or done by signing a form designated by the state (e.g. on a driver's license). It must be in writing with a signature. C. Under the Uniform Anatomical Gift Act, an individual can revoke consent for organ donation by either destroying the card or revoking the gift orally in the presence of two witnesses. D. Under the Uniform Anatomical Gift Act, nurses may serve as witnesses for individuals who wish to donate organs. /

A nurse is providing teaching for new parents on safe sleeping recommendations to reduce the risk of sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? A. "Room sharing is recommended while the infant sleeps." B. "Bundle the infant snugly in 2 blankets at bedtime." C. "Only use bumper pads that can be securely attached to the crib rails." D. "The side-lying position is safest for infant sleeping."

A. "Room sharing is recommended while the infant sleeps." Sharing a room during sleep has been found to decrease the incidence of SIDS. However, infants should have their own sleep space, such as a crib or bassinet. Bed sharing is not recommended. Incorrect Answers: B. To decrease the risk of suffocation, infants should be kept warm by dressing them in a one-piece sleep sack. C. Avoiding the use of bumper pads, blankets, pillows, comforters, and stuffed toys reduces the risk for SIDS. D. The supine position is recommended for reducing the risk of SIDS. //

A nurse is delegating a client care task to an assistive personnel (AP). Which of the following directions should the nurse give the AP? A. "This client needs to ambulate using a walker three times today." B. "Please record strict intake and output for this client." C. "This client needs to have blood glucose monitoring before each meal." D. "Please obtain vital signs from all the clients to whom you are assigned today."

A. "This client needs to ambulate using a walker three times today." This direction includes the type of task to be done, the frequency with which the task is to be performed, the duration of the task, and information about the mechanics of ambulating the client. Incorrect Answers: B. "Strict intake and output" does not provide enough direction for the AP. It does not explain how this expectation differs from "regular" intake and output and whether the values need to be reported to the RN. C. This direction does not provide a specific time or details for monitoring the client's blood glucose level. It does not clarify how the values should be documented and whether they should be reported to the RN. D. This direction does not identify the frequency at which this task is to be performed on each client or the parameters for reporting findings. ///

A nurse is preparing to administer a client's anticoagulant medication. The client states, "I don't like to take this medication. I always have to get my blood checked." Which of the following responses should the nurse make? A. "You can refuse the medication. I will notify your provider." B. "This medication is given all the time to clients, and they don't have a problem." C. "I will come back later to give you the medication." D. "You need to take this medication in order to feel better."

A. "You can refuse the medication. I will notify your provider." The nurse should act as an advocate for the client and acknowledge the client's right to refuse any medication or treatment offered. The nurse should inform the provider of the client's decision. Incorrect Answers: B. This response seems automatic and does not address the client's concerns. The nurse should respond by listening to the client's concerns and act as an advocate for the client. C. This response changes the subject and does not address the client's concerns. The nurse should respond by listening to the client's concerns and act as an advocate for the client. D. This response provides a sense of false reassurance and does not address the client's concerns. The nurse should respond by listening to the client's concerns and act as an advocate for the client. /

A charge nurse is teaching a group of clients in an assisted living facility about client rights. Which of the following pieces of information should the charge nurse include in the teaching? A. "You can request to review your personal medical records at any time." B. "A 20-day notice is required prior to you being transferred to long-term care." C. "An executor will be assigned to manage your financial affairs." D. "You will have a provider other than your primary physician assigned to your care."

A. "You can request to review your personal medical records at any time." Clients have the right to request their own medical records and should expect adequate and appropriate care from the facility's personnel. Incorrect Answers: B. A client has the right to a 30-day notice if transfer to a long-term facility is required. The 30-day notice is to assist the client with financial preparations and to promote the client's welfare. C. A client has the right to make independent choices, such as managing personal financial affairs. D. A client has the right to keep his/her provider and to choose a different provider if necessary. /

A nurse in an emergency department is caring for 4 clients. Which of the following findings requires the nurse to act as a mandatory reporter? A. A child who was left unsupervised for several hours at home and is being treated for a fractured leg B. A client who was admitted for pneumonia and reports having no heat or running water at home C. A client who has depression and a self-inflicted wrist laceration D. A public official who is admitted with alcohol withdrawal and delirium tremens

A. A child who was left unsupervised for several hours at home and is being treated for a fractured leg This child exhibits findings of neglect and endangerment. The nurse is a mandatory reporter for any client situation in which children or older adult clients are being abused or neglected. Incorrect Answers: B. This client would benefit from a referral to social services for assistance with living conditions. Mandatory reporting of this situation to legal authorities is not indicated. C. None of the information given indicates that this client is a danger to others. This client will likely be placed on suicide precautions, but disclosure to a legal authority is not indicated. D. Sharing this information outside the care team for this client is a violation of HIPAA regulations. Disclosure to a legal authority is not indicated. //

A nurse is planning care for several clients. Which of the following clients should the nurse refer to a case manager? A. A client who has neurological deficits following a stroke B. A married female client who has delivered a full-term newborn C. A client who is postoperative following a cholecystectomy D. A child who has a fracture of the dominant arm

A. A client who has neurological deficits following a stroke The nurse should refer this client to the case manager for care. A client who had a stroke will likely require long-term treatment. A client who has ongoing needs for care or rehabilitation should receive care that is directed by a case manager due to the complexity and cost of the client's needs. Incorrect Answers: B. If no complications or social concerns exist, the delivery of a full-term newborn does not require case management. C. As long as no complications occur, this procedure does not require a case management approach. D. A child who has a fractured arm does not require a case management approach unless there is evidence that some other pathology precipitated the fracture. /

A charge nurse is conducting an in-service training session on ethics to a group of newly licensed nurses. Which of the following situations should the charge nurse include as an example of the ethical principle of veracity? A. A nurse truthfully answers the client's questions about upcoming chemotherapy. B. A nurse stops inserting an NG tube when the client refuses the procedure. C. A nurse provides the same amount of time to all clients regardless of condition. D. A nurse reports an assistive personnel who transfers a client without using a gait belt.

A. A nurse truthfully answers the client's questions about upcoming chemotherapy. Veracity refers to telling the truth and being straightforward and clear with clients about the treatment being delivered. Incorrect Answers: B. A nurse who is inserting an NG tube but stops when the client refuses is demonstrating the ethical principle of autonomy. Autonomy is including the client in the decision-making process for all aspects of care, including treatment. C. A nurse who provides the same amount of time with all clients regardless of condition is demonstrating the ethical principle of justice, which involves fairness. D. A nurse who reports an assistive personnel who fails to follow the safety guidelines within the facility for transferring a client is demonstrating the ethical principle of responsibility. /

A nurse is admitting a client who has measles. This client should be placed in which of the following types of isolation? A. Airborne B. Contact C. Droplet D. Protective environment

A. Airborne The nurse should place the client who has measles in airborne isolation. Airborne isolation is used for clients who have infections that can be transmitted through droplets in the air that are smaller than 5 microns. Therefore, the nurse should place the client in a private room that has a negative-pressure airflow with at least 6-12 air exchanges per hour. The nurse should also wear an N95 respirator mask while caring for the client. Incorrect Answers:B. Contact isolation is used for clients who have infections that can be transmitted through direct contact or environmental contact. For contact isolation, the client should be placed in a private room or with another client who has the same infection. C. Droplet isolation is used for clients who have infections that can be transmitted through droplets in the air that are larger than 5 microns and by being within 1 m (3.3 feet) of the client. For droplet isolation, the client should be placed in a private room, and the nurse should wear a mask while providing care for the client. D. A protective environment is used for clients who are immunocompromised and susceptible to acquiring an infection. The nurse should put clients who require a protective environment in a private room with a positive airflow of 12 or more air exchanges per hour. Clients should also wear masks when going outside of the room or being transported. //

A nurse is preparing to provide discharge teaching to an older adult client. Which of the following teaching considerations should the nurse include? A. Allow frequent rest periods during teaching B. Use colored paper with a glossy finish C. Present the information at a tenth-grade reading level D. Use 12-point font size

A. Allow frequent rest periods during teaching The nurse should allow frequent periods of rest since an older adult client processes information more slowly. Incorrect Answers: B. The nurse should use white or buff-colored paper with a matte finish to avoid glare. C. The nurse should present the information at a sixth- to eighth-grade reading level. D. The nurse should use at least a 14-point font size for an older adult client when developing written materials. /

A nurse is caring for 4 clients who are scheduled for diagnostic tests. For which of the following tests should the nurse obtain written consent from the client? A. Cerebral arteriogram B. Magnetic resonance imaging (MRI) C. Computed tomography (CT) scan D. Carotid ultrasound

A. Cerebral arteriogram A cerebral arteriogram is considered invasive because it involves injecting contrast material into an artery to study the cerebral circulation. Written consent is required. B. An MRI is a noninvasive and painless procedure that does not require written consent. C. A CT scan uses a narrow radioactive beam to scan the body in successive layers. It is a noninvasive and painless procedure that does not require written consent. D. A carotid ultrasound is a noninvasive vascular test that evaluates arterial blood flow. It is used for screening or diagnosing stenosis or partial occlusion of the carotid arteries. An ultrasound is often obtained before more invasive tests are performed. /

A nurse is participating in an ethics committee meeting about a client who has a history of alcohol use disorder and needs a liver transplant. Which of the following actions should the committee take first? A. Collect information related to the issue. B. Consider the possible choices of action. C. Make a decision regarding transplant recommendation. D. Justify the recommendation for or against a transplant.

A. Collect information related to the issue. According to evidence-based practice, the committee should take the first step in ethical decision-making by identifying the ethical issue and problem. This step includes asking questions to define the issue and the complexities of the situation. Incorrect Answers: B. The second step in ethical decision-making involves identifying and analyzing all of the available alternatives for action, even if the actions seem unlikely. C. The third step in ethical decision-making involves selecting one of the alternative actions to follow. The committee should apply ethical principles to make the best decision possible. D. This is the final step in ethical decision-making. The committee should specify reasons for the action selected and be able to present the ethical basis behind the decision made. /

A nurse discovers that the wrong medication was given to a confused client who answered to the name the nurse stated when entering the room. The provider is notified and reports that the medication the client received will not cause any harm. Which of the following actions should the nurse take? A. Complete an incident report documenting the occurrence. B. Make a note in the client's medical record that an incident report was completed. C. Request that another nurse administer medications to this client for the remainder of the shift. D. Report the medication error to the Joint Commission.

A. Complete an incident report documenting the occurrence. An incident report should be initiated whenever an error is made involving a client, even if no injury occurred. Incident reports are also used for statistical purposes in determining the types of incidents that occur. These reports may help administrators recognize if a particular type of incident is occurring at an undesired frequency to determine if intervention is needed. Incorrect Answers:B. The nurse should not document in the client's medical record that an incident report was completed. C. Refusing to administer other medications is not realistic or practical. Although a negative outcome could have occurred, accepting responsibility for the error and learning from the situation is an important and professional response. D. The error should be acknowledged through proper documentation, which will provide evidence to the administration of factors that need to be addressed to rectify potentially unsafe practice issues. However, the nurse should not report the medication error to the Joint Commission. /

A nurse is planning care for a group of clients. Which of the following actions should the nurse plan to take? A. Delegate the administration of an intermittent tube feeding to a licensed practical nurse (LPN) B. Assign an assistive personnel (AP) to monitor a client's dressing for evidence of bleeding C. Ask an AP to explain to a client how to empty a urinary leg bag D. Delegate the administration of a unit of packed RBCs to a client to an LPN

A. Delegate the administration of an intermittent tube feeding to a licensed practical nurse (LPN) Administering a tube feeding is within the scope of practice for an LPN. Incorrect Answers: B. This task requires assessment skills that are not within the scope of practice of an AP. C. An LPN is responsible for client teaching or reinforcement of teaching. D. Although an LPN can assist an RN with packed RBC administration by monitoring clients receiving blood products, an LPN's scope of practice does not involve administering packed RBCs. /

A nurse manager is planning staff development activities for the unit's new unlicensed assistive personnel (UAP). Which of the following activities should the nurse manager perform first? A. Determine the learning needs of the UAPs B. Administer a skills pretest to the new UAPs C. Provide the new UAPs with a performance checklist D. Ask the UAPs about any weaknesses they may have

A. Determine the learning needs of the UAPs The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, he/she must first collect adequate data. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision; therefore, the nurse manager should first determine the learning needs of the UAPs. Incorrect Answers: B. Providing staff development can include administering tests to employees; however, this is not the action the nurse manager should perform first. C. Providing staff development can include offering a performance checklist to employees; however, this is not the action the nurse manager should perform first. D. Providing staff development can include asking employees about their weaknesses; however, this is not the action the nurse manager should perform first. //

A charge nurse in an emergency department is making assignments for an assistive personnel (AP) during a shift with unexpected staff absences. Which of the following assignments should the charge give to a float AP from the medical-surgical unit? A. Escorting clients from the emergency department to other areas of the facility for tests B. Sitting at the reception desk answering telephones and directing clients C. Restocking the examination rooms after each client is discharged D. Shadowing an AP who is regularly assigned to the emergency department

A. Escorting clients from the emergency department to other areas of the facility for tests Clients in the emergency department often require transport to other departments. Typically, transporting stable clients is a task that may be delegated to an AP, and escorting clients is likely a normal part of the AP's regular routine. Incorrect Answers: B. The receptionist at the emergency department desk is the first professional the client sees. Therefore, the personnel who staff the desk must have the necessary interviewing and observational skills to recognize seriously ill or injured clients who are in need of immediate triage. An AP who has never worked in the emergency department does not have these skills, so this is not an appropriate assignment. C. Examination rooms of the emergency department may have specialized equipment that is unfamiliar to the AP. Even if the drawers or supply carts are labeled, the AP could make mistakes. Since the equipment stocked in the treatment and examination rooms of the emergency department must be readily available in the event of an emergency, the rooms must be properly restocked between clients. D. While shadowing another AP is a good strategy for a typical day in the emergency department, during staffing crises this is an inappropriate expectation of the regularly assigned AP. //

A charge nurse is making daily assignments for a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Measuring vital signs B. Reinforcing an IV catheter dressing C. Conducting a preoperative admission assessment D. Showing a client how to use a walker

A. Measuring vital signs According to the National Council of State Boards of Nursing, delegation is the transferring of authority to perform a selected nursing task in a certain situation to a competent individual. Examples of tasks a nurse can delegate to an AP are measuring and documenting vital signs, performing postmortem care, and measuring and documenting intake and output. Incorrect Answers: B. Caring for invasive lines, performing triage, and creating a nursing care plan are not within an AP's range of function. C. Performing assessments, giving telephone advice, and interpreting data are not within an AP's range of function. D. Providing client education, evaluating the effectiveness of care, and inserting NG tubes are not within an AP's range of function. /

A client in a long-term care facility falls out of bed, fracturing his left hip. The side rails on the bed were not raised at bedtime, although this client was identified to be at risk of falling. Which of the following torts has occurred? A. Negligence B. Battery C. Intentional tort D. Slander

A. Negligence Negligence occurs when a client is exposed to an unreasonable risk of injury. Raised side rails help decrease the risk of falling out of bed and are a standard of care for clients who have been identified as at risk of falling. Incorrect Answers: B. Battery is defined as touching a client without consent. C. An intentional tort occurs when a person willfully injures another in some manner. D. Slander is an injury to one's reputation caused by spoken word. /

A nurse receives the morning change-of-shift report and delegates several tasks to an assistive personnel (AP) on the team. Which of the following tasks should the nurse instruct the AP to perform first? A. Obtain the morning capillary blood glucose tests B. Bathe a client scheduled for physical therapy at 0900 C. Distribute the breakfast trays D. Fill pitchers with fresh water and ice

A. Obtain the morning capillary blood glucose tests The nurse should apply the urgent vs nonurgent priority-setting framework when delegating tasks. The nurse should prioritize urgent needs because they pose more of a threat to the client. The nurse may need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Insulin administration is dependent on the blood glucose levels; therefore, the most urgent task the AP should complete is obtaining the morning capillary blood glucose tests. Incorrect Answers: B. Bathing a client who is scheduled for physical therapy is a nonurgent task and can wait until after the client has had breakfast. C. Distributing the breakfast trays is nonurgent. Clients who might need insulin should not have their trays until after blood glucose readings have been obtained. D. Filling pitchers with fresh water and ice is important to allow clients to maintain hydration, but it is nonurgent and can wait until after breakfast. /

A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? A. Paralysis of a client's lower extremities occurred following epidural anesthesia. B. A client fall during ambulation did not result in client injury. C. A client's family member complained that a nurse was culturally insensitive. D. Surgery to the wrong site was stopped prior to a procedure.

A. Paralysis of a client's lower extremities occurred following epidural anesthesia. An incident resulting in permanent harm, such as paralysis or death, is a sentinel event. Sentinel events are a high priority and indicate the need for an immediate investigation. Incorrect Answers: B. The committee should review this incident and policies to reduce the risk and occurrence of falls in the facility; however, a client fall that does not result in injury is not a sentinel event. C. The committee should review the incident and policies to promote culturally competent care. However, this type of adverse event is not identified as a sentinel event. D. The nurse should identify this type of incident as a near-miss, which happens when an error is caught and prevented before it occurs. //

A charge nurse is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)? A. Perform a simple dressing change. B. Interpreting a client's blood glucose reading C. Providing advice when speaking to a client's family member on the phone D. Determining the effectiveness of a client's urinary catheter

A. Perform a simple dressing change. The nurse should identify that the completion of a simple dressing change is within the AP's range of function. Therefore, the charge nurse can delegate this task to an AP. Incorrect Answers: B. Interpreting a client's blood glucose reading is a type of assessment, which is outside the range of function for an AP. Therefore, this task should be delegated to a nurse. C. Providing advice when speaking to a client's family member on the phone can involve assessment and evaluation, which are outside the range of function for an AP. Therefore, this task should be delegated to a nurse. D. Determining the effectiveness of a client's indwelling urinary catheter can involve assessment and evaluation, which are outside the range of function for an AP. Therefore, this task should be delegated to a nurse. ///

An RN is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to a licensed practical nurse (LPN)? A. Performing tracheostomy suctioning for a client who is stable B. Preparing an admission assessment for a client who is preoperative C. Creating a plan of care for a client who has COPD D. Interpreting a client's digoxin level

A. Performing tracheostomy suctioning for a client who is stable An RN may delegate the task of performing tracheostomy suctioning for a client who is stable or whose tracheostomy is not new to the LPN. This task is within the LPN's scope of practice. Incorrect Answers: B. Preparing an admission assessment for a client who is preoperative is outside the LPN's scope of practice. This involves assessment and is the responsibility of the RN. RNs cannot delegate aspects of the nursing process, client education, or tasks that require nursing judgment to LPNs. C. Creating a plan of care for a client who has COPD is outside the LPN's scope of practice. This involves assessment and is the responsibility of the RN. D. Interpretation of a client's digoxin level is outside the LPN's scope of practice. This involves assessment and is the responsibility of the RN. /

A nurse is writing a goal for a client's reaction following the administration of a medication. This action should take place during which of the following phases of the nursing process? A. Planning B. Evaluation C. Analyzing D. Assessment

A. Planning The nurse should write expected outcomes as part of the planning phase of the nursing process. During planning, the nurse establishes goals and outcomes for the client and selects the interventions that will help achieve those goals and outcomes. Planning also involves setting care priorities. Incorrect Answers: B. During the evaluation phase of the nursing process, the nurse uses critical thinking skills to determine whether application of the nursing process and implementation of the treatment plan have resulted in an improvement in the client's status. This phase does not involve goal setting. C. During the analysis/diagnosis phase of the nursing process, the nurse uses critical thinking skills to identify the client's health status or problems, interpret data, reach a nursing judgment about the client's health status and coping mechanisms, and provide direction for nursing care. This phase does not involve goal setting. D. During the assessment phase of the nursing process, the nurse uses critical thinking skills to collect subjective and objective data about the client to help plan the appropriate interventions. This phase does not involve goal setting. //

A nurse is preparing a client for discharge. The client states, "My partner hurts me. I don't want to go home." Which of the following actions should the nurse take? A. Refer the client to social services for assistance in seeking safe housing B. Delay the discharge until the client's partner can be interviewed C. Ask the client to document any further violence for the authorities D. Contact the facility security officer to escort the client to the vehicle

A. Refer the client to social services for assistance in seeking safe housing It is the duty of the nurse to assist the client in finding safe housing and protection from the offending partner. Incorrect Answers: B. It is the nurse's responsibility to report the alleged abuse, not to investigate the validity of the allegation. C. The nurse's responsibility is to protect the client and report the suspected abuse to the authorities. D. The nurse should assist the client in finding safe housing and protection from the offending partner. /

A school nurse is assessing a child who has multiple bruises on his trunk and extremities. The child reports falling out of a tree 2 days ago. The nurse's assessment findings show patterns of bruising that are not typically sustained during a fall from a tree. Which of the following actions should the nurse take? A. Report the findings to local police and social service agencies. B. Report the findings to the school district superintendent. C. Call the parents of the child and further assess the causative event. D. Reassess the child on a weekly basis for injuries.

A. Report the findings to local police and social service agencies. Health care providers are required to report suspected child abuse. The nurse's primary concern is the safety of the child. Procedures for reporting differ in various locations, but procedures involve notification of police and social services personnel who can investigate the situation. Incorrect Answers: B. The nurse should report suspicions of abuse to the authorities and should not share private information with others within the school system. C. The physical assessment findings support a suspicion of abuse. The nurse should report this suspicion to the authorities for further investigation. The nurse's legal responsibility is the safety of the child. D. If abuse is occurring in the child's home, waiting to intervene could put the child at risk for further abuse or serious injury. The nurse is obligated to report the suspicion of abuse immediately. /

A nurse is walking with a client who falls after the facility-issued walker loses a wheel. Which of the following actions should the nurse take regarding the completed incident report? A. Submit the variance report to the risk manager. B. Place the variance report in the client's chart. C. Document the completion of the incident report in the client's medical record. D. Make a copy of the variance report for the provider.

A. Submit the variance report to the risk manager. Incident reports are confidential documents used by the institution to improve client care. Filing an incident report does not supersede the need for documenting the assessment in the client's medical record and notifying the provider. Once completed, the variance form should be submitted to the institution's risk manager. Incorrect Answers:B. Incident reports are confidential documents used to improve client care. The nurse should not place the report in the client's chart. C. The nurse should not document the completion of an incident report in the client's medical record. D. The nurse should not make a photocopy of the incident report, as this would allow attorneys to subpoena a copy of the report for potential use in litigation. /

A nurse is providing teaching about a living will for a client who has end-stage breast cancer. Which of the following pieces of information should the nurse include in the teaching? A. The client has the right to change the living will at any time. B. The client should be certain of the decision because the document establishes guidelines for refusing resuscitation. C. A durable power of attorney is required with a living will. D. The handwritten living will is not a legal document and cannot be included in the client's medical record.

A. The client has the right to change the living will at any time. A living will is one component of advance directives. This legal document that expresses the client's wishes regarding health care decisions in the event the client becomes incapacitated or is unable to make decisions. The client has the right to change or revoke the living will at any time. Incorrect Answers: B. A living will often can address treatments that have the capacity to prolong life. Examples of treatments include cardiopulmonary resuscitation, mechanical ventilation, and feeding by artificial means. A living will does not automatically result in a do-not-resuscitate (DNR) order. The provider should consult with the client and the family prior to administering a DNR order. The DNR order must be written in the client's chart for each hospitalization. C. A durable power of attorney is a legal document that designates a person to make health care decisions for the client when the client is no longer able to do so. However, this is not a requirement for a living will. D. Living wills can be handwritten. The nurse should identify that a living will is part of advance directives. The Patient Self-Determination Act (PSDA) requires asking all clients admitted to a health care facility if they have advance directives. A client without advance directives must be given written information that outlines rights related to health care decisions and how to formulate advance directives. /

A nurse manager notes that a full-time nurse has been absent from work 6 times over the last 6 weeks. Using a nonpunitive approach, which of the following actions should the nurse manager take? A. Verbally remind the employee about the facility's employment standards. B. Recommend that the employee review the facility's policy regarding absences. C. Inform the employee in writing about the facility's employment policy. D. Ask the employee for a written action plan after discussing the reasons for these absences.

A. Verbally remind the employee about the facility's employment standards. Verbal admonishment is the first step in the disciplinary process for this type of infraction. The employee might not know or remember the existing standard, and a verbal reminder may be sufficient to change the employee's behavior. Incorrect Answers: B. Recommending that the employee reviews the policy does not ensure that the employee will read and fully understand the employment standards. C. Written admonishment is the second step in the disciplinary process for this type of infraction. If the employee fails to make a positive behavioral change after being verbally reminded by the manager about the facility's employment standards, the nurse manager should inform the employee in writing. D. This is an example of performance-deficiency coaching, which the nurse manager should use to correct unacceptable behaviors over time. ///

A nurse is caring for a client who has a history of severe multiple sclerosis and asks the nurse about completing a living will. Which of the following statements should the nurse make? A. "I will provide you with the information you need to complete advance directives." B. "I will contact your provider to inform him of your desire to complete a living will." C. "Your attorney will need to review the document before it can be enacted." D. "Once your living will is complete and on file, the choices you make are final."

A. "I will provide you with the information you need to complete advance directives." Under the Patient Self-Determination Act, health care institutions are required to provide educational materials advising clients of their rights to make personal wishes known regarding treatment. Incorrect Answers: B. The nurse does not need to contact the provider unless the client has questions for the provider concerning treatment options. The nurse will contact the provider and document in the medical record once the client has completed a living will. C. This document does not require the review of an attorney. D. The nurse should inform the client that even if a living will is completed, the decision can always be changed. //

After a disaster plan is enacted, a nurse in a pediatric unit is asked to prepare a list of clients who can be discharged home due to a local incident involving many children. Which of the following clients should the nurse place on the potential discharge list? (Select all that apply.) A. A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol B. A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine C. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics D. A toddler with a ventricular septal defect and bronchiolitis who is on 28% oxygen by oxyhood E. An adolescent client who is 1 day postoperative following scoliosis repair and is on a PCA pump

A. A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol B. A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine C. An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics The nurse should place clients who can be quickly and safely discharged on the potential discharge list. Children who have asthma can be managed at home once the acute phase of illness has resolved. Because the preschool client's manifestations are responsive to the prescribed medication, this child can be safely discharged home with appropriate discharge teaching and follow-up care planning. External fixation devices are worn for weeks to months; they are often managed at home once the device is placed and the client has learned how to care for the immobilized limb. This school-age client's pain is responsive to oral codeine. Prior to discharge, the client might need instructions on ambulation and weight-bearing, as prescribed. Long-term antibiotic therapy is typically completed in the home following PICC line placement. A visiting nurse can assist this adolescent client with home care management. The client's developmental delay has no bearing on whether the client is safe to discharge. Incorrect Answers:D. This toddler with a chronic health problem (a congenital heart defect) is now experiencing an acute illness (severe lower respiratory illness). Because the client's increased care needs may potentially cause more complex problems, the child is not considered safe to discharge. E. Clients are typically hospitalized for 4-6 days following scoliosis (curvature of the spine) repair (spinal fusion). This client is still on a PCA pump for pain control and is only 1 day postoperative. Commonly, spinal fu

A charge nurse is planning a department in-service training session about radioactive implants for a group of staff nurses. Which of the following points should the charge nurse include in the presentation? (Select all that apply.) A. Clients should be placed in a private room. B. Throw away an implant that has fallen out in the client's trash can. C. Staff members should wear a dosimeter badge when caring for the client. D. Clients should be on bed rest. E. Children over the age of 12 years can visit if they are accompanied by an adult.

A. Clients should be placed in a private room. C. Staff members should wear a dosimeter badge when caring for the client. D. Clients should be on bed rest. Clients should be placed in a private room to avoid exposing other clients to radiation from the implant. The nurse should follow the principles of time, distance, and shielding when working with a client who is receiving internal radiation therapy. Health care providers should wear a dosimeter badge while caring for a client who has a radioactive implant. This badge measures and records a staff member's amount of exposure to radiation. Clients who have a radioactive implant should remain on bed rest while the implant is in place to prevent dislodgement. Incorrect Answers: B. The nurse should pick up a radioactive implant that has fallen out with forceps and place it in a lead container. E. Children under the age of 16 years and women who are pregnant are prohibited from visiting a client who has a radioactive implant. ///

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.) A. Collecting a stool specimen B. Providing instructions about using a spirometer C. Measuring oral intake D. Providing postmortem care E. Changing a sterile dressing

A. Collecting a stool specimen C. Measuring oral intake D. Providing postmortem care The nurse should delegate collecting a stool specimen, measuring oral intake, and providing postmortem care to the AP. These tasks do not require assessment, analysis, or teaching and are within the range of function for an AP. Incorrect Answers: B. Providing instructions about using a spirometer is a form of teaching and is outside the range of function for an AP. E. Changing a sterile dressing is outside the range of function for an AP. APs cannot perform nursing actions that require assessment. //

A nurse manager is evaluating the time-management strategies of a newly licensed nurse on the pediatric unit. Which of the following actions taken by the nurse are effective time-management strategies? (Select all that apply.) A. Completing one task before beginning another task B. Documenting client care at the end of the shift C. Taking time to plan care at the beginning of the shift D. Completing more time-consuming tasks at the end of the shift E. Mentally visualizing a procedure prior to gathering equipment

A. Completing one task before beginning another task C. Taking time to plan care at the beginning of the shift E. Mentally visualizing a procedure prior to gathering equipment Completing one task before beginning another task, planning care at the beginning of the shift, and mentally visualizing a procedure prior to gathering equipment are effective time-management strategies for the newly licensed nurse. Daily planning is important for managing and prioritizing tasks. Incorrect Answers: B. Documenting client care at the end of the shift is not an effective time management strategy. The newly licensed nurse should document care as soon as possible after an intervention is completed to facilitate accuracy and thorough documentation. D. Completing more time-consuming tasks at the end of the shift is not an effective time management strategy. The newly licensed nurse should complete more difficult or strenuous tasks earlier in the day when energy levels are higher. This strategy also helps avoid procrastination. /

A nurse working at a rehabilitation facility is attending an interdisciplinary team meeting for a client who had a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse recommend to assist this client? (Select all that apply.) A. Nurse B. Occupational therapist C. Speech therapist D. Physical therapist E. Respiratory therapist

A. Nurse B. Occupational therapist C. Speech therapist D. Physical therapist The role of the nurse is to attend the interdisciplinary meeting to present the client's condition and possible needs. The occupational therapist is needed to assist the client with activities of daily living and to enhance independence (e.g. eating, dressing, bathing, grooming, and feeding). The speech therapist is needed to assist the client with difficulties related to speech and swallowing as a result of the stroke. The speech therapist can also conduct an initial evaluation, complete a swallowing assessment, and provide ongoing speech therapy. The physical therapist is needed to discuss and manage the client's physical impairments related to mobility as a result of the stroke. Ongoing physical therapy is needed to assist the client with learning how to walk again while using an assistive device, such as a cane or a walker. Incorrect Answer: E. The client is not experiencing respiratory challenges that require the assistance of a respiratory therapist as a result of the stroke. ///

A nurse suspects that a coworker is under the influence of alcohol. Which of the following behaviors in the workplace are consistent with substance use disorder? (Select all that apply.) A. Taking extended lunch periods and breaks B. Calling in sick frequently on Mondays or Fridays C. Expressing frustration with work assignments D. Demonstrating decreased concern about personal appearance and grooming E. Using excessive amounts of cologne or mouthwash

A. Taking extended lunch periods and breaks B. Calling in sick frequently on Mondays or Fridays D. Demonstrating decreased concern about personal appearance and grooming E. Using excessive amounts of cologne or mouthwash Extended lunch periods and breaks may indicate that the individual is ingesting alcohol in a remote location. Calling in sick frequently on Mondays or Fridays may imply that the individual is binge drinking on weekends and is too ill to come to work. Decreased concern about personal appearance and grooming and excessive use of cologne or mouthwash are signs of substance use disorder. Incorrect Answer: C. Frustration with assignments is a common workplace behavior but does not necessarily indicate substance use disorder. ///

A nurse manager is presenting an in service about preventing readmission of clients due to complications after joint replacement surgery. Which of the following leadership tasks is the nurse performing?

Advocacy

A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated to an assistive personnel (AP)? (Select all that apply.)

Ambulating a client who uses a walker is correct. This is within the AP's scope of practice. Adding thickener to thin liquids on a client's food tray is correct. This is within the AP's scope of practice.

A nurse is discussing with a newly licensed nurse about how to obtain informed consent from a client who is scheduled to undergo an epidural procedure. Which of the following ethical principles should the nurse include in the teaching? A. Beneficence B. Autonomy C. Paternalism D. Justice

Autonomy Informed consent is based on the ethical principle of autonomy, which is the right to self-determination, independence, and freedom of choice. Incorrect Answers: A. Beneficence is based on the principle that actions should be taken with the intent to do good. It is associated with nonmaleficence, which is the requirement that health care providers do no harm to their clients. Although this is an important ethical principle in nursing, it is not the basis for informed consent. C. Paternalism is based on the assumption that one person can assume responsibility for making the decisions of another person. This principle limits freedom of choice. D. Justice is based on the principle that everyone should be treated similarly and fairly. This is an important ethical principle but is not the basis for informed consent. //

A nurse is caring for a child who has sustained extensive head injuries. The provider has diagnosed brain death. Which of the following statements should the nurse use to begin a conversation about the option of organ and tissue donation with the child's parents? A. "I want to talk to you about the importance of considering the donation of your child's organs for transplantation." B. "I want to give you some information about an option that you have regarding donating your child's organs to others who are in need." C. "I am legally required to inform you that you can donate your child's organs for transplantation." D. "Have you ever considered donating your organs for transplantation?"

B. "I want to give you some information about an option that you have regarding donating your child's organs to others who are in need." This is an appropriate statement to begin the discussion. It clearly conveys the nurse's intention to give the family factual information and does not make any emotionally-laden statements. Incorrect Answers: A. This is a strong statement of the nurse's belief that organ donation is the right thing to do. It is not appropriate to make the family feel guilty if they choose not to donate. C. This focus on a legal requirement might imply that the nurse does not support the idea of organ donation. The nurse should avoid statements that lead the family one way or another. D. Asking the family members about their thoughts on donating their own organs shifts the focus away from the immediate situation. /

A nurse from a facility's float pool receives an assignment to float on a nursing unit. The float nurse tells the charge nurse that she has never worked on this unit before. How should the charge nurse respond? A. "I'll be sure to give you an easy assignment so you won't have any difficulty adjusting to our unit." B. "I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you." C. "Don't worry about that. Come find me if you have any questions, and I will try to help." D. "I'll call the supervisor and ask if another float nurse is working who has experience with our unit."

B. "I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you." Providing the float nurse with a co-assigned resource person is appropriate. This resource is part of a float pool, not just a nurse floating from another unit, and it is likely that she will be assigned to this unit in the future. The charge nurse can facilitate her orientation to the unit by providing a resource person who is skilled in the care provided to clients on the unit. Incorrect Answers: A. While the charge nurse should not overwhelm the float nurse with a difficult assignment, providing the float nurse with an easy assignment will not address the need to be properly oriented to the unit. C. The charge nurse should provide the float nurse with a specific resource nurse who is skilled in the care provided to clients on the unit. D. It is appropriate to facilitate the float nurse's orientation to the unit by providing a resource instead of questioning her abilities by indicating that another nurse would be better. /

A 13-year-old female client tells the charge nurse in the pediatric unit that she does not want the male nurse assigned to care for her. Which of the following responses should the nurse make? A. "I will need to discuss your request with your parents first." B. "I'll change the assignment so a female nurse is caring for you today." C. "A female assistive personnel will be helping with your bath." D. "The male nurse assigned is required to care for both male and female clients."

B. "I'll change the assignment so a female nurse is caring for you today." The client has the right to respect and personal dignity and the ability to participate in decisions regarding her care. The charge nurse should change the assignment when possible to minimize any feelings of loss of control for this client. Incorrect Answers: A. Although this client is a minor, she still has the right to participate in decisions regarding her care. This response by the nurse suggests that the client's feelings are not important and that she has no say in the matter. C. While having female assistive personnel help the client with bathing would prevent physical exposure during this activity, other care requirements may also make the client uncomfortable. The client has the right to respect and personal dignity. D. This statement negates the client's feelings and does not address her right to respect and personal dignity. /

A home health nurse is caring for a client who asks about the purpose of a living will. Which of the following statements should the nurse include in the teaching? A. "It establishes who will make health care decisions for the client if the client is not able to do so." B. "It allows the client to express personal wishes regarding health care decisions." C. "It serves as an informed consent form for any procedure prescribed by a provider." D. "It is only valid when a client is lucid and able to make informed decisions independently."

B. "It allows the client to express personal wishes regarding health care decisions." A living will allows the client to specify what aspects of care and treatment are to be accepted or refused in the event that the client can no longer communicate those decisions. Incorrect Answers: A. This describes a health care proxy document, which frequently accompanies a living will but is not considered a part of it. C. A living will does not serve the same function as informed consent. Prior to any procedure, consent must always be obtained from the client, a family member, or a designated health care proxy. D. A living will is not valid or necessary when a client is able to make informed health care decisions independently. /

A nurse is planning care for a client following a coronary arterial bypass graft procedure. The nurse places a referral for a case manager to visit the client. Which of the following pieces of information should the nurse share with the client about the role of a case manager? A. "The case manager will provide your direct care for the remainder of your stay in the facility." B. "The case manager will coordinate and plan your care while you recover from your surgery." C. "The case manager will meet with you on the day before your scheduled discharge date." D. "The case manager is responsible for completing your insurance claim forms."

B. "The case manager will coordinate and plan your care while you recover from your surgery." The role of the case manager is to coordinate and plan client care, collaborate with other health professionals, and monitor costs and quality of care. Incorrect Answers: A. A case manager will coordinate the care of a client as an inpatient and assist with discharge planning. Case managers do not complete direct client care. C. The case manager is involved in client care throughout the client's stay in the facility, serving as a facilitator and care coordinator. The case manager does not wait until the time of discharge to meet with the client. D. The case manager is responsible for facilitating the use of cost-effective care measures during hospitalization but is not responsible for completing insurance claim forms. /

A charge nurse is performing a quality-assurance audit on the documentation of several clients' charts. Which of the following documentation items should the charge nurse identify as a correct entry in the client's medical record? A. "The client appeared angry when family members were visiting." B. "The client ambulated for 10 min three times during the shift." C. "The client seemed to be upset about the diagnosis." D. "An incident report was completed when the client fell at 1000."

B. "The client ambulated for 10 min three times during the shift." The charge nurse should identify that this documentation item reflects objective data about the client's actions. Incorrect Answers: A. This documentation item is an interpretation of the client's feelings. The documentation should use client quotes about how the client is feeling when documenting subjective data rather than relying on the nurse's perception of the client's emotions. C. This documentation item is an interpretation of the client's feelings. The documentation should use client quotes about how the client is feeling when documenting subjective data rather than relying on the nurse's perception of the client's emotions. D. Documentation about the completion of an incident report should never be noted in the client's medical records. The nurse can document information about the events surrounding the incident in the medical record (e.g. the fall and resulting client outcomes). //

A group of nurses on a telemetry unit informs a nurse manager of a need to update the cardiac monitoring system to improve arrhythmia detection. Which of the following responses should the nurse manager make? A. "This purchase will require the completion of a variance analysis." B. "This purchase will need to be addressed in the capital budget plan for the unit." C. "This purchase will result in a reduction in the operating budget." D. "This purchase can be reimbursed by Medicare funds, as clients who use Medicare will benefit from the equipment."

B. "This purchase will need to be addressed in the capital budget plan for the unit." The capital budget involves planning for spending related to equipment and major purchases that have a long life of use. Incorrect Answers: A. The anticipated purchase of new equipment does not require a variance analysis. Variance analysis is a process that differentiates planned budget results from actual results. C. An operating budget is separate from the budget for large expenditures for equipment or other major purchases. This type of budget reflects expenses that change in response to the volume of service (e.g. supplies, electricity). D. Medicare funds do not reimburse institutions for equipment purchases, even though clients who are receiving Medicare use the equipment. ///

A nurse is delegating tasks to an assistive personnel (AP) for the care of a group of clients. Which of the following directions should the nurse provide? A. "Take the temperature of the client in room 200." B. "Transport the client in room 203 to the radiology department at 1000." C. "Obtain the vital signs of the client in room 205 when he returns from surgery." D. "Contact the provider of the client in room 208 regarding her decreased hemoglobin level."

B. "Transport the client in room 203 to the radiology department at 1000." This statement observes the rights of delegation. It provides an appropriate task within the AP's scope of practice and offers the right communication by telling the AP which client to transport, where to take the client, and what the time the client needs to be at the radiology department. Incorrect Answers: A. This statement fails to provide the right communication for the AP. It does not offer a timeframe for when the task needs to be completed or give the AP the information necessary for reporting the results. C. This statement does not address the correct task. A client returning from surgery is not considered stable, and the nurse will need to assess this client prior to delegating care to the AP. D. This statement does not address the right person. Contacting the provider with client information regarding a decreased hemoglobin level is not within the scope of practice for the AP. //

A charge nurse is making shift assignments for a team that includes RNs, licensed practical nurses (LPNs), and assistive personnel. Which of the following clients should the nurse assign to an LPN? A. A client who was just admitted by the unit staff for recurring angina B. A client who has emphysema and pneumonia and is receiving oxygen C. A client who has breast cancer and is receiving chemotherapy D. A client who was just admitted by the unit staff for a cerebrovascular accident

B. A client who has emphysema and pneumonia and is receiving oxygen This client requires routine care, medication administration, and data collection. This is an appropriate client to assign to an LPN. Incorrect Answers: A. This client needs an initial assessment, stabilization, and care planning; therefore, this is an appropriate client to assign to an RN, not an LPN. D. This client needs an initial assessment, stabilization, and care planning; therefore, this is an appropriate client to assign to an RN, not an LPN. C. This client's care requires specialized IV and medication training and expertise; therefore, this is an appropriate client to assign to an RN, not an LPN. //

A nurse is teaching a group of newly licensed nurses about violations of client rights. Which of the following examples of a violation of client rights should the nurse include in the teaching? A. A client who is confused and recovering from abdominal trauma has mitten restraints placed to prevent disruption of an abdominal wound. B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex. C. A health care proxy releases the medical records of a client to a long-term care facility for a placement evaluation. D. The parents of a 16-year-old who has gunshot wounds decide to limit their child's visitors to family members only.

B. A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex. Seclusion is a restraint that should be used when a client is demonstrating violent or self-destructive behavior that jeopardizes the safety of self or others. This client does not meet the criteria for seclusion. Incorrect Answers: A. This client is at risk of causing self-injury by disrupting the abdominal wound. The nurse should apply mitten restraints, which are less restrictive than wrist restraints. C. The client's health care proxy has the authority to consent to the release of medical records. D. A 16-year-old client is a minor; therefore, the client's parents have the right to make this decision for the client. //

A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A. A client who is to be discharged with a peripherally inserted central catheter (PICC) line B. A client who is disoriented and awaiting a transfer to a long-term care facility C. A client who is 16 hours postoperative following a total laryngectomy D. A client who is newly admitted for abdominal pain of unknown origin

B. A client who is disoriented and awaiting a transfer to a long-term care facility A client who is disoriented will need observation and reality orientation, which is within the LPN's scope of practice. The client's condition can also be categorized as stable since discharge to a long-term care facility is scheduled. Incorrect Answers: A. A client who has a PICC line will require discharge teaching related to PICC line home care which is not within the LPN's scope of practice. C. A client who has a new tracheostomy is not considered stable and will require frequent assessment, which is not within the LPN's scope of practice. D. A newly admitted client should be assessed by the nurse. This client will also be undergoing many diagnostic tests and will require frequent assessment, which is not within the LPN's scope of practice. //

A charge nurse is evaluating conflict resolution between two staff nurses. Which of the following conflict-resolution styles is an example of one nurse putting aside personal goals to satisfy the other nurse? A. Avoidance B. Accommodation C. Compromise D. Collaboration

B. Accommodation Accommodation is when one person puts aside personal goals to satisfy the needs of another individual. This nurse is using accommodation in order to resolve the conflict. Incorrect Answers: A. Avoidance is when one person uses passive behaviors and withdraws from a conflict, preventing either individual from pursuing personal goals. C. Compromise is when both individuals give up something to achieve a common goal. D. Collaboration is when both individuals actively try to find a solution that is acceptable to all parties. //

A nurse is speaking with the family member of a client who has early Alzheimer's disease. The family member would like to keep the client living at home, but the client requires assistance while the family member is away at work. Which of the following services should the nurse include in the discussion? A. Hospice care B. Adult day care C. Assisted-living facility D. Long-term care facility

B. Adult day care Adult day care personnel can provide constant assistance with ADLs while the family member is at work; the client can live at home during the night and evening hours. Incorrect Answers: A. Hospice care is only appropriate for a client who has a terminal illness and a life expectancy of <6 months. C. Clients who live in an assisted-living facility need to be able to live independently and require minimal assistance. Clients can receive assistance with medication and are offered one prepared meal a day if needed. However, an assisted-living facility is not an option at this time since the family member wishes to keep the client at home. D. A long-term care facility is not an option at this time since the family member wishes to keep the client at home. /

A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at the greatest risk for a complication? A. A 3-year-old client who has a burned foot B. An 80-year-old client who has a fractured hip C. A 30-year-old client who has a cast applied for a fractured ankle D. A 42-year-old client who has an indwelling urinary catheter

B. An 80-year-old client who has a fractured hip The nurse should identify that an 80-year-old client who has a fractured hip is at the greatest risk for a complication due to immobility and a lack of lower-extremity movement, which can lead to deep-vein thrombosis (DVT). DVT is caused by venous stasis and blood clot formation in the vascular system and can lead to pulmonary emboli. The nurse should encourage the client to ambulate as soon as prescribed and implement range-of-motion exercises while on bedrest to prevent DVT. Incorrect Answers: A. This 3-year-old client is at risk for developing an infection if the dressings are not kept intact and clean. Children who are otherwise healthy are extremely mobile and generally experience optimal healing. Therefore, another client is at greater risk for a complication. C. This 30-year-old client is at risk for developing compartment syndrome if an excess amount of swelling develops. Excess swelling is rare but can restrict blood flow to the extremity and cause nerve damage. Therefore, another client is at greater risk for a complication. D. This 42-year-old client who has an indwelling urinary is at risk for developing a urinary tract infection but only as a result of possible contamination from poor technique during insertion of the catheter or contamination during catheter care. Therefore, another client is at greater risk for a complication. /

A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail of his bed. Which of the following actions should the nurse take? A. Tell the client that he will be put in restraints if he attempts to get out of bed again. B. Ask an assistive personnel to sit with the client. C. Remind the client to stay in bed. D. Restrain the client immediately to prevent self-harm.

B. Ask an assistive personnel to sit with the client. This client is at risk of falling. Having an assistive personnel sit with the client protects him from harm. Then, the nurse can contact the provider to discuss care options for this client (e.g. restraints or placing an audible alarm). Incorrect Answers: A. The nurse in this situation is threatening the client with restraints if a change in behavior does not occur, which is a form of assault. C. This client is at risk of falling, and this action will not promote the client's immediate safety. Nurses are negligent for failing to make provisions for client safety when the situation requires. D. The nurse should apply restraints only when necessary to protect the client from harm and after all other alternative measures are exhausted. //

A nurse is working with an assistive personnel (AP) who appears to be under the influence of alcohol during the night shift. Which of the following is the priority action for the nurse? A. Confront the AP regarding alcohol use and remove him from client care. B. Ask the nursing supervisor to observe the AP and validate these suspicions. C. Document observations made about the AP's behavior in a factual manner. D. Report the incident to the nurse manager in the morning.

B. Ask the nursing supervisor to observe the AP and validate these suspicions. After gathering data, the nurse must first validate these suspicions with another observer, take the appropriate action to safeguard clients, and then document the incident. Incorrect Answers: A. The second step in handling this situation is to confront the AP and remove him from client care to protect the clients from unsafe practice. C. In conjunction with confronting the AP and removing him from client care, the nurse should document observations made in regard to the AP's behavior in a factual manner. D. It is the nurse manager's responsibility to discuss disciplinary and chemical impairment recovery program options with the AP. Documentation of the nurse's observations will assist the nurse manager in developing an appropriate plan for dealing with the issue. //

A nurse is delegating a task to an assistive personnel (AP). The AP is to transfer a client who has a below-the-knee amputation from a bed to a wheelchair. The AP has never transferred a client with an amputation before. Which of the following actions should the nurse take? A. Provide the AP with a manual on how the transfer should be done. B. Assist the AP after he has practiced the transfer. C. Transfer the client while the AP observes. D. Ask another AP to transfer the client.

B. Assist the AP after he has practiced the transfer. The safest way for the nurse to determine if the AP has the knowledge and skill to transfer the client who has an amputation is by having the AP practice and demonstrate the task. By assisting the AP with the first transfer, the nurse helps ensure that delegated care is safely provided. Incorrect Answers: A. Providing a manual on the procedure alone will not adequately ensure the safety of the client during the transfer. C. Although this strategy may be used to demonstrate to the AP how to transfer an amputee, it does not allow hands-on practice for the AP. D. While this action will accomplish the task of transferring the client, it does not address the AP's need to learn how to transfer a client who has an amputation. ///

A nurse has several tasks to complete while preparing a client scheduled for surgery. Which of the following tasks can the nurse delegate to an assistive personnel (AP)? A. Verify the client's list of allergies in the medical record B. Assist with placing the client onto the stretcher for transport to the surgical suite C. Complete the preoperative checklist for the client D. Call to inform the provider about the client's preoperative elevated blood glucose level

B. Assist with placing the client onto the stretcher for transport to the surgical suite Helping the client onto the stretcher for transport to the surgical suite is a skill that is within the scope of practice for the AP. Incorrect Answers: A. Verifying the client's allergies is a part of the preoperative assessment data. This is not within the scope of practice for the AP. C. A preoperative checklist is a tool for ensuring client safety and completion of nursing interventions. This documentation should be completed by the nurse, as it is not within the scope of practice for the AP. D. The nurse should call to inform the provider about the client's elevated blood glucose level. Although the AP may have obtained the high blood glucose reading, it is not within the scope of practice of an AP to call the provider. The provider might give a prescription for medication over the phone, which a nurse should transcribe into the client's medical record. /

A nurse is updating the plan of care for a client who has celiac disease. Which of the following dietary selections should the nurse recommend for the client? A. Whole-wheat tortilla with black beans B. Baked chicken and rice C. Turkey and cheese sandwich D. Pasta with marinara sauce

B. Baked chicken and rice The nurse should recommend baked chicken and rice as a dietary selection for a client who has celiac disease. Clients who have celiac disease should avoid foods containing gluten. Incorrect Answers:A. A client who has celiac disease should avoid eating whole-wheat tortillas because wheat is a source of gluten. C. A client who has celiac disease should avoid eating turkey and cheese sandwiches because processed deli meat and bread may contain gluten. D. A client who has celiac disease should avoid eating pasta because pasta is a source of gluten. /

A nurse is caring for a client who is undergoing a repair of an abdominal aortic aneurysm. After the surgery and immediate postoperative recovery, the nurse should expect which of the following team members to coordinate the client's ongoing and specific needs for care? A. Charge nurse B. Case manager C. Vascular surgeon D. Home health care nurse

B. Case manager The case manager's role is to plan and coordinate resources and services to help meet the client's needs over the continuum of care. Incorrect Answers: A. The charge nurse's responsibilities include focusing on the day-to-day operations of the nursing unit, not on the specific needs of individual clients. C. The surgeon's responsibilities focus on intraoperative care as well as immediate postoperative needs, postoperative care, and management of complications. D. The home health care nursing staff's responsibilities include meeting the client's care needs, not coordinating them. //

After entering a client's room, a nurse notices the client has fallen on the bathroom floor. Which of the following actions should the nurse perform first? A. Obtain support from another nurse B. Check the client for injuries C. File an incident report D. Notify the client's provider

B. Check the client for injuries The greatest risk to this client is an injury from falling on the floor; therefore, the first action the nurse should take is to look for skin tears, cuts, or bruises and to obtain the client's vital signs. Incorrect Answers:A. The nurse should obtain support from another nurse before filing the incident report if additional information or a witness is needed; however, the nurse should take another action first. C. The nurse should file an incident report to record the client's fall and to prevent future falls; however, the nurse should take another action first. D. The nurse should notify the client's provider about the fall and communicate whether the client was injured and needed treatment; however, the nurse should take another action first. /

A nurse enters a client's room and finds the client lying on the floor next to the bed. Which of the following actions should the nurse take first? A. Determine the cause of the incident. B. Check the client for injuries. C. Call for assistance to get the client back into bed. D. Complete an incident report.

B. Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine whether the client has sustained any injuries from the fall and implement interventions to ensure the client's safety and wellbeing. Incorrect Answers: A. The nurse should determine the cause of the incident to prevent further risks; however, there is another action the nurse should take first. C. The nurse should call for assistance to place the client back into bed; however, the client should not be moved until an assessment by the nurse has been completed. D. The nurse should complete an incident report with factual information regarding the incident; however, there is another action the nurse should take first. /

A nurse manager establishes staff nurse committees to address unit issues, institutes an open-door policy for speaking about concerns, and supports professional staff development. Which of the following leadership styles is this nurse manager displaying? A. Laissez-faire B. Democratic C. Autocratic D. Transactional

B. Democratic The democratic manager encourages the staff to participate in decision-making, communicates effectively, offers constructive criticism, and believes the best of people. Incorrect Answers: A. A laissez-faire manager provides little structure or direction for a group. C. An autocratic management style is characterized by behaviors such as making all decisions without staff input, focusing on task completion, and limiting access to communication with the manager. D. A transactional leader focuses on getting work done and the tasks to be completed. /

A nurse manager calls a meeting of the unit's staff members to discuss cost-containment issues. The nurse manager has asked for staff input regarding strategies to help reduce costs. Which of the following types of leadership is the nurse manager using? A. Autocratic B. Democratic C. Laissez-faire D. Moral

B. Democratic This is an example of democratic leadership. A democratic leader guides staff toward an objective and shares responsibility with the staff. This is the ideal type of leadership in this situation because a great amount of creativity can occur, and many strategies can be developed. Incorrect Answers: A. An autocratic leader makes decisions independently and notifies staff of the decisions made. An autocratic manager maintains a high degree of control and allows little freedom of staff members. C. A laissez-faire leader exerts little or no leadership and control. This manager is providing staff with direction and leadership. D. Moral leadership involves honesty and fairness under any circumstances. /

A nurse is assisting a provider with an amniotomy on a client who is in labor. Which of the following is the priority nursing assessment following the procedure? A. Color of amniotic fluid B. Fetal heart rate C. Uterine contraction pattern D. Odor of amniotic fluid

B. Fetal heart rate The greatest risk to this client is an injury from umbilical cord prolapse following artificial rupture of the membranes; therefore, the nurse should monitor the fetal heart rate for bradycardia, which can indicate an increased risk of umbilical cord prolapse. Incorrect Answers: A. The nurse should assess the color of the amniotic fluid for blood or meconium stool to check for fetal distress. However, another assessment is the priority. C. The nurse should assess the client's uterine contraction pattern to determine if oxytocin should be given to stimulate contractions. However, another assessment is the priority. D. The nurse should assess the odor of the amniotic fluid to check for infection. However, another assessment is the priority. /

A nurse in an acute care facility is implementing the facility's disaster plan following a flood in the community. Which of the following actions should the nurse take? A. Turn on clients' televisions so they can learn about the disaster. B. Identify stable clients in the ICU to transfer to the medical-surgical unit. C. Ask family members to come to the hospital to provide support to clients. D. Make announcements of the status of the disaster on the public address system.

B. Identify stable clients in the ICU to transfer to the medical-surgical unit. The nurse should identify clients to transfer to the medical-surgical unit to increase the availability of ICU beds for clients from the external disaster who are critically ill. Incorrect Answers:A. The facility's communication officer is responsible for informing clients about the external disaster. C. The nurse should avoid placing the client's family members at risk by asking them to travel during a natural disaster. D. The facility's communication officer is responsible for making announcements to clients and others in the facility about the external disaster. /

A nurse is administering medications to a client who is recovering from a stroke and has right-sided paralysis. The nurse places the client's medications on the left side of the mouth and administers pills one at a time. Which of the following ethical principles is the nurse displaying? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice

B. Nonmaleficence Nonmaleficence is the duty to do no harm and to protect clients from harm by eliminating threats. These actions taken by the nurse are important for the safety of the client by preventing aspiration. Incorrect Answers: A. Autonomy is the right to self-determination, independence, and freedom of choice. C. Fidelity is the obligation to be faithful to commitments made to self and others. D. Justice is the obligation to be fair and to treat people in an equal manner. /

A nurse in the emergency department is preparing to obtain informed consent for surgery from a client who received a meperidine hydrochloride IV during transport from a rural hospital. Which of the following actions should the nurse take to obtain consent for surgery? A. Obtain consent from the client. B. Obtain consent from a relative of the client. C. Consent is implied because the client agreed to be transported to the emergency department. D. Delay the surgery until the medication has been metabolized.

B. Obtain consent from a relative of the client. A client who has received meperidine cannot give consent because the medication can alter the ability to understand the consent process. The nurse should obtain consent from a relative of the client. If a relative is unavailable and the surgery is determined to be critical, the surgery can proceed without client consent. Incorrect Answers: A. This client has been given a narcotic that can alter the ability to understand the consent process. The client cannot give consent under these circumstances. C. Consent for transfer to another facility for evaluation by a specialist does not assume consent for any further procedures, surgery, or care. D. Delaying surgery until the medication is metabolized may cause the client unnecessary pain and increase the risk of complications and client demise. If a relative is unavailable and the surgery is determined to be critical, the surgery can proceed without client consent. ///

A nurse is caring for a client who had a stroke and requires assistance performing ADLs. The nurse should collaborate with which of the following members of the interprofessional care team? A. Speech-language pathologist B. Occupational therapist C. Social worker D. Dietitian

B. Occupational therapist An occupational therapist can help clients who have physical limitations or disabilities gain an optimal level of independence in performing ADLs, such as bathing, dressing, grooming, and eating. Incorrect Answers: A. Although a speech-language pathologist can help clients who have swallowing disorders and communication difficulties, a speech-language pathologist cannot help clients with the manual motor skills they need for eating and performing other ADLs independently. C. Although a social worker can assist clients with accessing community resources and services, such as meal delivery and educational programs, a social worker cannot help clients with the manual motor skills they need for eating and performing other ADLs independently. D. Although a dietitian can help clients with meeting nutritional needs and finding resources for obtaining and preparing food, a dietician cannot help clients with the manual motor skills they need for eating and performing other ADLs independently. /

A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as part of an effective conference? A. The planning process for the conference is centered on the nursing staff. B. Other health care professionals are in attendance at the conference. C. Controversial opinions regarding the plan of care are not tolerated during the conference. D. The conference is focused on a discussion of the client's health care issues with minimal attention to resolving them.

B. Other health care professionals are in attendance at the conference. The nurse should identify that an effective conference should consist of other health care professionals who contribute to the plan of care for goal setting and seek to establish positive client outcomes. The members of the conference consist of the nursing team who should invite other health professionals (e.g. physical therapists, dieticians, and occupational therapists) to contribute to the plan of care. Incorrect Answers: A. The planning process for the conference should address goals related to the client's care plan and positive client outcomes. C. During any client care plan conference, there will be differences of opinion. Therefore, it is important to encourage a climate of respect and a nonjudgmental attitude so that all attendees can work toward remaining open-minded about other attendees' contributions. This can lead to more productive sharing and positive client outcomes. D. The purpose of the conference is to develop resolutions for the numerous client care problems that require an interprofessional team to set goals and measurable positive outcomes. /

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? A. Showing the client how to use the patient-controlled analgesia pump. B. Recording urinary output after emptying the indwelling urinary catheter. C. Assisting the client out of bed and into a chair for the first time after surgery. D. Checking the client's abdominal wound dressing.

B. Recording urinary output after emptying the indwelling urinary catheter. Emptying an indwelling urinary catheter and recording intake and output are within the scope of practice for an AP. These tasks are routine and have predictable outcomes; therefore, the nurse may delegate this task to an AP. Incorrect Answers: A. Client education is not within the scope of practice of an AP. C. Assisting a client out of bed for the first time after surgery is not within the scope of practice of an AP. The client must be medically stable for the nurse to delegate this task to an AP. D. Checking a surgical incision dressing is not within the scope of practice of an AP. This task requires assessment and should be performed by the nurse. /

A nurse is preparing a client for a lumbar puncture. The client has signed the consent form but tells the nurse that she does not remember what the doctor will do during the procedure. Which of the following actions should the nurse take? A. Page the provider stat to come and explain the procedure to the client. B. Remind the client that the doctor will insert a needle to get a sample of fluid from her spine. C. Explain how the assistant will position the client for the procedure. D. Tell the client that someone will explain the procedure when it is time to begin.

B. Remind the client that the doctor will insert a needle to get a sample of fluid from her spine. A signed consent form indicates that the provider informed the client about the procedure and that at the time the client understood what to expect. If the client states she does not remember what to expect, the nurse should clarify any details the provider previously gave the client. However, if the client expresses a further lack of understanding or states that the provider did not inform her, the nurse should either notify the charge nurse or call the provider directly. Incorrect Answers: A. The signed consent form indicates that the provider explained the procedure to the client previously. The nurse should have confirmed this when witnessing the consent. C. Although the nurse should provide this information, this response does not clarify what the provider will do once the client is in position and directs the focus away from what the client wants to know. D. This response is nontherapeutic, rejects the client's concern, and fails to identify the need for the nurse to take further action. ///

While caring for a client, a nurse notices that the client's call light cord is frayed. Which of the following actions should the nurse take? A. Tell the client not to use the call light until it is fixed. B. Replace the call light and send the frayed one to the repair department. C. Tape the frayed area of the cord until maintenance can fix it so the client can continue to use the call light. D. Provide the client with a bell and advise using the call light only in an emergency.

B. Replace the call light and send the frayed one to the repair department. For client safety, the client needs to have access to a call light to notify the nursing staff for assistance. A frayed cord is an electrical hazard. Removal of a frayed cord is the best way to protect the client from potential electrical shocks or burns. Incorrect Answers:A. This action does not protect the client from potential electrical burns or shocks or provide a way for the client to signal for assistance. C. This is not a proper repair, and it will not protect the client from potential electrical burns or shocks. D. Providing the client with a bell offers an alternative to signal the nursing staff for assistance; however, telling the client to use the call light in an emergency does not protect the client from potential electrical burns or shocks when the call light is used. /

A nurse working in a mental health facility is preparing to discharge a client who has schizophrenia and requires assistance with housing. Which of the following referrals should the nurse recommend to the provider? A. Occupational therapist B. Social worker C. Physical therapist D. Spiritual support

B. Social worker The nurse should identify that a social worker assists clients with issues such as finances, day-to-day concerns, and suitable housing options. Incorrect Answers: A. An occupational therapist assists clients with activities of daily living such as dressing, bathing, and using utensils when eating. C. A physical therapist assists clients with mobility issues by increasing strength and endurance. D. Spiritual support services assist clients with meeting religious needs. /

A nurse is planning care for a client who has COPD, requires continuous oxygen therapy, and is being discharged to return home. Which of the following referrals should the nurse recommend? A. Spiritual advisor B. Social worker C. Physical therapist D. Occupational therapist

B. Social worker The nurse should recommend a referral to a social worker when a client will require additional services, such as home health care, oxygen therapy, hospice care, or wound care. Incorrect Answers: A. The nurse should recommend a referral to a spiritual advisor for a client who requests spiritual counsel or guidance. C. The nurse should recommend a referral to a physical therapist for a client who requires assistance with mobility and range-of-motion activities of the upper and lower extremities. D. The nurse should recommend a referral to an occupational therapist for a client who has difficulty performing ADLs. //

A nurse in a provider's office observes a newly licensed nurse taking a client's health history while in the waiting area. Which of the following actions should the nurse take? A. Continue to observe the nurse B. Speak to the nurse immediately in private C. Consider using the same practice to make efficient use of time and office space D. Report the nurse's actions to the provider

B. Speak to the nurse immediately in private The newly licensed nurse is violating client confidentiality and federal HIPAA regulations. Personal health information could be overheard by others in the waiting room. The nurse must immediately stop this behavior and speak to the newly licensed nurse in private to protect the privacy and confidentiality of the client. Incorrect Answers: A. Further observation is not necessary. The newly licensed nurse is violating client confidentiality and federal HIPAA regulations. C. Even though nurses should use time efficiently and make the best use of office space, they also need to respect a client's right to privacy and confidentiality of personal health information. D. This action is not necessary. The nurse should stop this practice to protect the client's right to privacy and confidentiality. /

A nurse is part of a facility committee charged with developing and implementing new documentation forms. The nurse should recognize which of the following factors as a potential restraining force for implementing this change? A. Approval of the forms by the nursing administration B. Staff members' resistance to learning new forms of documentation C. Recognition of the facility unit that completes the implementation first D. Development of high-quality monitoring tools for compliance with new documentation

B. Staff members' resistance to learning new forms of documentation Restraining forces impede change. Staff members' resistance to learning a new documentation system can be a restraining force. As a result, the committee must develop a plan for implementation that recognizes this threat. A. Approval of the new documentation forms occurs as part of the process of development, and the committee should complete this step before implementation. C. Recognition serves as a driving force for implementation rather than a restraining force. D. The development of tools to monitor compliance with new documentation forms is part of the evaluation phase, not the implementation phase. /

A charge nurse is providing teaching to a new staff nurse about the management of a team consisting of a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following pieces of information should the charge nurse include in the teaching? A. The LPN can delegate the task of teaching a client about foot care to the AP. B. The LPN should be familiar with the task she plans to delegate. C. The person who accepts the delegated task also assumes accountability for the task. D. The LPN can delegate an initial assessment of a client to the LPN.

B. The LPN should be familiar with the task she plans to delegate. The nurse should be familiar with the task she plans to delegate so she can define the task as well as the expectation of its completed status, monitor the performance of the task, and provide feedback regarding the performance. Incorrect Answers: A. The nurse should not delegate the task of teaching a client about foot care, as this task is not within the scope of practice for an AP. C. While the person who accepts the delegated task assumes the responsibility for the task, accountability for any delegated task remains with the nurse who delegated it. D. It is the responsibility of the registered nurse to complete the initial assessment of a client admitted to a nursing unit. //

A nurse is caring for an adult client who has pancreatitis. The client tells the nurse, "I've decided that I want to go home. I don't want any more treatment." The nurse should recognize that which of the following legal principles applies to the client? A. The admitting provider needs to approve the client's request to leave. B. The client has the right to make the decision to leave the hospital. C. The client should be detained if leaving presents a risk of loss of life or limb. D. The client must demonstrate self-care abilities prior to leaving the acute-care facility.

B. The client has the right to make the decision to leave the hospital. Even though the nurse and the provider may think it inadvisable, a client who is not involuntarily admitted has the right to decide to leave at any time. Nurses and providers have a responsibility to ensure that the client is aware of potential risks and injury that can result from leaving and refusing further treatment before discharging the client against medical advice. The nurse should fully document this information and the client's response in the medical record. Incorrect Answers: A. The provider does not have to approve the client's request. The nurse should, however, notify the provider of the client's statement. C. The client has the right to leave the facility, even if doing so creates a risk of loss of life or limb. The nurse has the legal obligation to inform the client of such risks, but it is the client's decision whether to stay and continue treatment or to leave. D. The ability to perform self-care is not a criterion for denying a client's decision to leave the facility. The nurse should discuss the decision with the client and make sure the client understands the advisability of staying. The nurse should also complete discharge instructions and fully document the circumstances. /

A nurse is evaluating a client's understanding of discharge teaching about dressing changes. Which of the following actions by the client indicates an understanding of the teaching? A. The client nods and smiles in response to what is being said. B. The client restates the information in her own words. C. The client does not ask questions when given the opportunity. D. The client's body language shows that she is listening to the nurse.

B. The client restates the information in her own words. When the client restates the information in her own words, the nurse can assess the client's understanding of the teaching. The nurse can observe and listen for gaps in understanding and proceed to correct items as necessary. Incorrect Answers: A. Nodding and smiling at what the nurse says does not indicate an understanding of the teaching. The client may be using this response to show respect for the nurse. C. The client should have an opportunity to ask questions to clarify the information provided by the nurse. However, a lack of questions does not indicate an understanding of the teaching because the client might not ask questions about items that she did not understand. D. Although watching the client's body language can be helpful, this is not the best way to assess her understanding of the teaching. Body language is subjective and can have different meanings for the client than for the nurse. /

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following situations should the nurse complete a variance report? A. A clarification of a medication dosage prescribed by a provider B. The discovery that a preoperative client has received and eaten breakfast C. The identification of a safety concern with a piece of equipment D. A dispute with a coworker about client assignments

B. The discovery that a preoperative client has received and eaten breakfast This situation represents a variation from the standard of care. A change in the client's plan of care is necessary because the surgical procedure will need to be delayed. The nurse should complete a variance report for this situation. Incorrect Answers:A. It is the nurse's responsibility to clarify prescriptions that might pose a safety issue for the client. This situation does not require a variance report. C. If the nurse identifies a safety concern with a piece of equipment, it should be removed from use, and the nurse should follow the facility's procedure for placing a work order for repair. This situation does not require a variance report. D. This staff problem should be resolved between the coworkers with possible mediation by the nurse manager. This situation does not require a variance report. ///

A nurse in a community health clinic is planning an in-service staff training session on nationally notifiable infectious conditions. Which of the following conditions should the nurse include in the teaching? A. Clostridioides difficile B. Varicella C. HIV exposure D. Influenza

B. Varicella The nurse should identify that varicella is a nationally notifiable infectious condition. Incorrect Answers:A. C. difficile is not a nationally notifiable infectious condition. C. HIV infection is a nationally notifiable infectious condition, but HIV exposure is not. D. Influenza is not a nationally notifiable infectious condition, but influenza-associated pediatric mortality is a nationally notifiable infectious condition. ///

A nurse is providing discharge teaching about wound care to a client who has a leg wound. Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Use cotton balls to clean the infected areas. B. Cleanse the wound with tap water. C. Dry the leg wound after cleaning. D. Microwave the cleaning solution before applying to the wound. E. Discard soiled bandages in a moisture-proof bag.

B. Cleanse the wound with tap water. E. Discard soiled bandages in a moisture-proof bag. Tap water or 0.9% sodium chloride should be used to cleanse the wound. Soiled bandages and gloves should be placed in double-bagged, moisture-proof bags and not in the regular trash. This prevents the spread of contamination to other family members within the household. Incorrect Answers: A. Cotton balls should not be used because the fibers can get caught in the wound and cause an infection; therefore, gauze squares or nonwoven swabs should be used to clean the wound. C. Drying the leg wound after cleaning should be avoided. The wound should be open to the air to allow the wound to retain moisture and promote healing. D. The nurse should warm the cleaning solution to the client's body temperature if possible; however, using a microwave to warm the solution can make it too hot. ///

A charge nurse on a medical-surgical unit is assigning client care to the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.) A. Performing colostomy care B. Measuring a client's intake and output C. Interpreting a client's laboratory values following surgery D. Providing postmortem care to a client E. Checking nasogastric tube patency

B. Measuring a client's intake and output D. Providing postmortem care to a client Measuring the intake and output of a client and providing postmortem care are within the range of function for an AP. Incorrect Answers: A. Performing colostomy care involves data collection, which is outside the range of function for an AP. This task should be delegated to a licensed practical nurse (LPN). C. Interpreting a client's laboratory values following surgery involves data collection and is outside the range of function for an AP. This task should be delegated to an LPN. E. Checking nasogastric tube patency should be delegated to an LPN, not an AP. ///

A nurse is making a client's bed and finds a capsule of medication in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice? (Select all that apply.) A. Administer the medication to the client. B. Notify the provider. C. Complete a variance report. D. Document the finding in the client's electronic medical record. E. Place the medication back in the medication drawer.

B. Notify the provider. C. Complete a variance report. B. Notifying the provider is correct. The nurse should notify the provider of the finding as a part of the variance reporting process. C. Completing a variance report is correct. The nurse should complete an incident or variance report regarding the occurrence. Incorrect Answers: A. Administering the medication to the client is incorrect. The nurse should not administer the medication to the client, because the nurse does not know which dose of the medication the client missed. Administering the capsule now could result in an overdose if the client has recently taken the same medication. D. Documenting the finding in the client's electronic medical record is incorrect. The nurse should not document the finding in the client's electronic medical record. The nurse should identify that information in the client's medical record is subject to attorney review should the client decide, for any reason, to file suit against the facility or the healthcare staff. Instead, the nurse should follow facility policy and report the incident to the nurse manager and risk management through the use of a variance report. In addition, the nurse should avoid documenting in the medical record that a variance report was filed because this can also allow for the variance report to be subpoenaed should the client decide to file suit. E. Placing the medication back in the medication drawer is incorrect. The nurse should identify that medications that are no longer packaged are considered contaminated and should be discarded. ///

A charge nurse is planning an in-service training session about client advocacy with a group of staff nurses. Which of the following situations should the nurse include as an example of client advocacy? (Select all that apply.) A. Discussing treatment options with a client who was diagnosed with pancreatic cancer B. Notifying the provider when a client has questions about the procedure C. Helping a client make a list of questions to ask the provider D. Clarifying the dosage of a medication prescribed for a client who has impaired liver function E. Carrying out the end-of-life wishes outlined in the living will of an older adult client who has end-stage renal disease

B. Notifying the provider when a client has questions about the procedure C. Helping a client make a list of questions to ask the provider D. Clarifying the dosage of a medication prescribed for a client who has impaired liver function E. Carrying out the end-of-life wishes outlined in the living will of an older adult client who has end-stage renal disease As a client advocate, the nurse should make sure clients have all their questions answered and possess the information needed to make an informed decision. Clarifying the dosage of a medication prescribed for a client who impaired liver function can prevent medication toxicity and demonstrates client advocacy. Carrying out the end-of-life wishes of a client who has end-stage renal disease demonstrates client advocacy. Incorrect Answer: A. Discussing treatment options for a client who has pancreatic cancer is outside the scope of practice for a nurse. This is the responsibility of the provider. The provider should discuss treatment options with the client, including risk, benefits, and alternative treatments. ///

A nurse is preparing to teach the health care team about the concept of critical pathways. Which of the following statements about the purpose of a critical pathway should the nurse plan to include? A. "A critical pathway is a plan of care specific to the nursing interventions necessary for client care." B. "A critical pathway is a tool that legally binds the health care facility to provide services as outlined." C. "A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." D. "A critical pathway is a plan that may be the same for several similar diagnoses."

C. "A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." A critical pathway outlines the actions that members of the health care team must complete in a timely manner to achieve desired client outcomes and an appropriate length of stay for the particular diagnosis. Incorrect Answers: A. Critical pathways address appropriate nursing care and actions that other disciplines are responsible for as well. They provide a holistic approach to the plan of care. B. Critical pathways are not legal documents. Critical pathways establish the standard of care in an institution, but variances from the pathway often occur for multiple reasons. Documentation of these variances is important, along with the revised plan to correct or address the variance. D. Critical pathways are developed for individual diagnoses. They are based on the typical interdisciplinary needs and length of stay for that particular diagnosis. ///

A nurse is caring for a client who asks if the client in the next room is in pain because she cries out frequently. Which of the following statements should the nurse make? A. "That client has cancer and is quite uncomfortable." B. "We are doing our best to keep that client as comfortable as possible." C. "Does the crying out bother you?" D. "Why don't you ask that client's family when they visit?"

C. "Does the crying out bother you?" This therapeutic response focuses on the client's feelings rather than on confidential information concerning the client in the next room. It summarizes the client's question and poses an open-ended, relevant query for the client to expand on if desired. Incorrect Answers: A. Revealing another client's diagnosis is an invasion of privacy and a violation of the Health Insurance Portability and Accountability Act (HIPAA) regulations. B. This nontherapeutic statement by the nurse uses a defensive response. It ignores the client's concerns because the nurse is focusing on defending the health care team. D. This nontherapeutic response by the nurse changes the subject and does not address the client's concerns. It also ignores the right to privacy for the other client. //

A nurse is teaching a newly licensed nurse about advanced directives. Which of the following statements by the newly licensed nurse indicates an understanding of this teaching? A. "Clients are required to complete an advance directive prior to discharge." B. "If the client has a health care proxy, he/she is no longer consulted for health care decisions." C. "I will assess the client's understanding of life-sustaining measures." D. "I will ask the next of kin if I should honor the client's advance directive."

C. "I will assess the client's understanding of life-sustaining measures." The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures in order to make informed decisions in advance directives. Incorrect Answers: A. The Patient Self-Determination Act requires all health care facilities receiving Medicare and Medicaid reimbursement to ask clients if they have advance directives, but it does not require a client to complete them during hospitalization. B. The health care proxy designates someone else to make health care treatment decisions when the client is unable to do so, based on the client's wishes. If the client is alert and oriented, the nurse should consult the client for health care decisions. D. The Patient Self-Determination Act requires health care facilities receiving Medicare and Medicaid reimbursement to recognize advance directives. These directives allow clients to specify aspects of care they wish to receive if they become unable to communicate these preferences. /

A nurse is caring for a client who has cancer. The client tells the nurse he does not want any more chemotherapy treatments. Which of the following responses should the nurse provide? A. "I think you should finish this round of treatments and then see how you feel." B. "I will discuss this decision with the designee in your health care proxy." C. "I will inform your provider of your decision to discontinue the treatments." D. "I am so sorry to hear you are tired of fighting and have made this decision."

C. "I will inform your provider of your decision to discontinue the treatments." The nurse has a duty to respect the client's right to refuse medical treatment. If a client under the nurse's care refuses treatment, the nurse also has a duty to notify the provider, who should give the client information about the consequences, risks, and benefits of refusing therapy. Incorrect Answers: A. This is a nontherapeutic response by the nurse. It offers a personal opinion that is not based on sound medical advice. B. A health care proxy designates someone chosen by the client to make decisions on behalf of the client when he/she is no longer capable of making decisions. This client is making this treatment decision, so the nurse does not need to consult the designee. D. This is a nontherapeutic response. Conveying sympathy expresses sorrow or pity for the client and does not offer a clear perspective on the situation. /

A nurse is caring for a client who has breast cancer and is scheduled for a mastectomy. The client tells the nurse she is concerned about how her partner will react to the procedure. Which of the following responses should the nurse make? A. "I will inform your surgeon that you are having second thoughts." B. "I think you should postpone the surgery until you are certain you want to have it done." C. "Would you like me to have a member of a breast cancer support group visit you?" D. "This is a common concern of women who will be undergoing a mastectomy."

C. "Would you like me to have a member of a breast cancer support group visit you?" The nurse should serve as an advocate for this client. Offering to have a member of a breast cancer support group visit the client allows the client to speak with someone who has been through the same experiences and can assist with the emotional aspects of having a mastectomy. Incorrect Answers: A. This is a nontherapeutic response by the nurse. It changes the subject and demonstrates a lack of empathy with the client's concerns. B. This is a nontherapeutic response by the nurse and offers a personal opinion rather than professional advice to the client. D. This nontherapeutic response by the nurse makes a stereotypical remark about women undergoing a mastectomy and is insensitive to the client's concerns. //

A charge nurse on a medical-surgical unit is making client assignments for the oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A. A client who requires an updated plan of care following a diagnosis of cancer B. A client who is postoperative following a total hip replacement and requires discharge teaching C. A client who has a prescription for irrigation of an indwelling urinary catheter D. A client who has just arrived from PACU and requires a head-to-toe assessment

C. A client who has a prescription for irrigation of an indwelling urinary catheter It is within the scope of practice of an LPN to irrigate an indwelling urinary catheter when prescribed by a provider. Incorrect Answers: A. B. D. An RN should perform these tasks /

A nurse is preparing to care for a group of clients after receiving change-of-shift reports. Which of the following clients should the nurse assess first? A. A client who has benign prostatic hyperplasia (BPH) and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

C. A client who has emphysema and reports dyspnea The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the client who has emphysema and reports dyspnea is the first client the nurse should assess. Incorrect Answers:A. The nurse should assess the client who has BPH and reports dysuria; however, this is an expected finding, so another client should be assessed first. B. The nurse should assess the client who has ulcerative colitis and reports diarrhea; however, this is an expected finding, so another client should be assessed first. D. The nurse should assess the client who has esophageal cancer and reports painful swallowing; however, this is an expected finding, so another client should be assessed first. /

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients should the nurse attend to first? A. A client who is receiving metoclopramide and reports diarrhea B. A client who is receiving tamsulosin and reports feeling dizzy C. A client who is receiving cephalexin and reports dyspnea D. A client who is receiving erythromycin and reports epigastric pain

C. A client who is receiving cephalexin and reports dyspnea The greatest risk to this client is an injury from dyspnea due to an allergic reaction from the antibiotic. The client is at risk of anaphylactic shock with a compromised airway; therefore, the nurse should first discontinue cephalexin and notify the provider immediately. Emergency equipment should be placed in the client's room in case the client goes into anaphylactic shock. Incorrect Answers: A. The nurse should attend to a client who is receiving metoclopramide and reports diarrhea, which is an adverse effect of this medication. The client should be monitored for dehydration; however, the nurse should attend to the more urgent client situation first. B. The nurse should attend to a client who is receiving tamsulosin and reports dizziness, which is an adverse effect of this medication. However, the nurse should attend to the more urgent client situation first. D. The nurse should attend to a client who is receiving erythromycin and reports epigastric pain by offering the medication with food to minimize gastric irritation; however, the nurse should attend to the more urgent client situation first. /

A school bus crash in the community creates an urgent need for pediatric hospital beds. Which of the following clients should the nurse manager recommend for discharge? A. A school-age child who was admitted the day before with status asthmaticus B. A toddler admitted the day before who has dehydration and is receiving IV fluids C. A preschooler admitted with tonsillitis who has been receiving oral antibiotics for 24 hr D. An adolescent with acute glomerulonephritis whose urine output is 20 mL/hr

C. A preschooler admitted with tonsillitis who has been receiving oral antibiotics for 24 hr This preschooler admitted with tonsillitis is stable and is receiving oral antibiotics; therefore, the preschooler can be discharged with antibiotics to be continued at home. Incorrect Answers:A. This school-age child admitted the day before with status asthmaticus has an acute illness and is not considered stable; therefore, the child should remain hospitalized. B. A toddler admitted the day before with dehydration is not considered stable; therefore, the toddler should remain hospitalized. D. An adolescent who has acute glomerulonephritis and a urine output of 20 mL/hr is not stable; therefore, the adolescent should remain hospitalized. //

A nurse manager is participating in a root cause analysis following a sentinel event on the unit. Which of the following statements defines the purpose of a root cause analysis? A. A root cause analysis assists in preparing a legal defense for the event. B. A root cause analysis estimates the costs involved in the event. C. A root cause analysis investigates deviations from standards of care surrounding the event. D. A root cause analysis determines if employees involved in the event should be terminated.

C. A root cause analysis investigates deviations from standards of care surrounding the event. A root cause analysis is a function of quality improvement seeking to determine what factors led to a deviation from established standards of care that resulted in errors in client care. Incorrect Answers: A. A root cause analysis does not involve preparing a legal defense regarding a sentinel event. B. A root cause analysis is a function of quality improvement in client care. It does not examine the costs involved in a sentinel event. D. As part of the quality-improvement process, a root cause analysis does not focus on individual performance but on organizational processes that led to an event. The results of a root cause analysis may indicate that employees need counseling in an effort to improve the quality of client care. /

A nurse is caring for a client with stage 4 ovarian cancer who has decided to stop treatment and enter hospice care. Which of the following ethical principles is the nurse displaying by supporting the client in her decision? A. Responsibility B. Accountability C. Advocacy D. Confidentiality

C. Advocacy By following the ethical principle of advocacy, the nurse supports the client in the decisions she makes about her own health care. Incorrect Answers: A. By following the ethical principle of responsibility, the nurse upholds obligations. B. By following the ethical principle of accountability, the nurse answers for personal actions. D. By following the principle of confidentiality, the nurse protects the client's privacy and health care information. /

A nurse is performing a safety audit on all equipment used on the unit. Which of the following items should the nurse identify as a safety hazard? A. An electrical cord that is taped to the floor B. A protective cover that is placed over an unused outlet C. An electrical cord that is frayed toward the plug D. An electrical plug that has 3 prongs

C. An electrical cord that is frayed toward the plug The nurse should identify that an electrical cord that is frayed toward the plug is damaged and should not be used. Using an electrical cord that is damaged can increase the client's risk of acquiring an electrical shock. Incorrect Answers: A. An electrical cord taped to the floor prevents others from tripping over the cord or damaging it. B. A protective cover placed over an unused outlet prevents young children from playing with the outlet. D. An electrical plug with 3 prongs is a grounded piece of equipment, which provides a path of low resistance to stray electric currents. This is the only type of electrical equipment that should be used. /

A nurse finds a client standing next to his bed with the side rails raised. The client is visibly confused and not wearing an identification bracelet, and his IV is detached. The client states, "I can't remember my name." After assisting the client back into bed, which of the following actions should the nurse take next? A. Remind the client to use the call light. B. Restart the IV. C. Assess the client for injury. D. Put an identification bracelet on the client.

C. Assess the client for injury. The nurse should apply the nursing process priority-setting framework when caring for this client. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he/she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision. Incorrect Answers: A. The nurse should remind the client to use the call light to ensure the safety of the client, but there is a different action the nurse should take first. B. The nurse should restart the client's IV to continue medication therapy, but there is a different action the nurse should take first. D. The nurse should put an identification bracelet on the client, but there is a different action the nurse should take first. /

Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit. This nurse has limited experience with children. Which of the following actions should the nurse manager take? A. Provide constant supervision for the medical-surgical nurse. B. Have the medical-surgical nurse provide relief for unit nurses during break and lunch times. C. Assign a unit nurse to act as a resource for the medical-surgical nurse. D. Delegate assistive personnel tasks to the medical-surgical nurse.

C. Assign a unit nurse to act as a resource for the medical-surgical nurse. Assigning a nurse who usually works on the pediatric unit to assist the medical-surgical nurse will provide consistent support. Incorrect Answers: A. There is no indication that the medical-surgical nurse requires constant supervision. B. Having the medical-surgical nurse provide relief during breaks and lunchtimes is not an appropriate use of resources. D. Delegating unlicensed tasks to a nurse is not an appropriate use of resources. //

A group of providers is participating in a cardiopulmonary resuscitation effort for a client who is in cardiac arrest. Which of the following types of leadership is required for this group to function efficiently? A. Transformational B. Participative C. Autocratic D. Laissez-faire

C. Autocratic Autocratic leadership is most effective in an emergency situation. An autocratic leader will direct and issues commands that are necessary for successful cardiopulmonary resuscitation. Incorrect Answers: A. Transformational leadership is not appropriate for an emergency situation. A transformational leader gives group members responsibilities that will enhance their professional development. In cardiopulmonary resuscitation, one person must organize the group's actions and guide the resuscitation efforts. B. Participative leadership, also called democratic leadership, is not appropriate for an emergency situation. A participative leader serves as a resource person and facilitator and is non-directive. In cardiopulmonary resuscitation, one person must organize the group's actions. D. Laissez-faire leadership is not appropriate for an emergency situation. A laissez-faire leader demonstrates a non-directive approach. In cardiopulmonary resuscitation, one person must organize the group's actions and guide the resuscitation efforts. ///

A nurse is reviewing the medication administration record for a client and notes that the nurse from the previous shift gave double the dose of antihypertensive medication prescribed to the client. Which of the following actions should the nurse take first? A. File an incident report with factual information about the error B. Report the incident to the nursing supervisor C. Check the client's condition D. Notify the client's provider about the incident

C. Check the client's condition The greatest risk to this client is an injury from low blood pressure due to a double dose of antihypertensive medication. Therefore, the first action the nurse should take is to check the client's condition and obtain the client's vital signs, including blood pressure. Incorrect Answers: A. The nurse should file an incident report with factual information about the error to prevent further medication errors from occurring; however, the nurse should take another action first. B. The nurse should notify the nursing supervisor about the medication error and communicate the status of the client's condition; however, the nurse should take another action first. D. The nurse should notify the client's provider about the medication error and communicate the status of the client's condition to determine whether further treatment is needed; however, the nurse should take another action first. /

A nurse is caring for a client who is in the bathroom. The nurse hears a loud thud and, after opening the bathroom door, finds the client on the floor. What is the priority nursing action? A. Notify the provider of the fall. B. Call for help. C. Determine the client's level of consciousness. D. Complete an incident report.

C. Determine the client's level of consciousness. Checking the client's level of consciousness is the first action the nurse should take after a fall. This client might have had a vasovagal response while defecating, resulting in a temporary loss of consciousness that does not require CPR. Incorrect Answers: A. B. D. Determining the client's level of consciousness is the priority action, followed by calling for help, notifying the provider, and finally completing an incident report. /

Using high-quality monitoring tools, a facility committee identifies that clients who have congestive heart failure have an average length of stay of 5 days instead of the established standard of 3 days. Which step should the nurse implement next in the quality-improvement process? A. Educate staff members on shortening the length of stay for these clients B. Collect data regarding the length of stay for these clients C. Determine which actions can be instituted to address this problem D. Research the accuracy of the standard of care that has been accepted

C. Determine which actions can be instituted to address this problem Further analysis of data will identify factors that contribute to longer lengths of stay. Identifying actions to shorten the clients' lengths of stay is the next step in the process. Incorrect Answers: A. Education is an important aspect of quality improvement; however, the nurse should first analyze the data to determine the cause of the extended facility stays. B. The data has already been collected regarding the length of stay for this group of clients. Collecting additional data will delay a response to the problem. D. Standards of care are established following extensive research and reflect the best information available. ///

A nurse is preparing to transfer an older adult client to a long-term care facility. To promote continuity of care, which of the following actions should the nurse plan to take? A. Discuss the client's long-term recovery goals with him B. Discuss the client's nursing care needs with his provider C. Give a written summary of the client's nursing plan of care to the long-term care facility D. Review the client's nursing care plan with his family members

C. Give a written summary of the client's nursing plan of care to the long-term care facility A written summary of the client's nursing plan of care will convey his needs to the nurses who will be working with him in the long-term care facility. Incorrect Answers: A. Clients should always be informed participants in their plans of care; however, the nurse should provide this information directly to the nurses who will be caring for the client in the long-term care facility. B. This is not needed, even for clients who will continue to use the same provider. The nurse should provide this information directly to the nurses who will be caring for the client in the long-term care facility. D. The client's family members should always be participants in the plan of care with his consent; however, the nurse should provide this information directly to the nurses who will be caring for the client in the long-term care facility. //

A nurse is preparing an IM injection for a client who is preoperative when another client suddenly calls for assistance. The nurse asks another nurse to give the injection since an assistive personnel is waiting to take the client to surgery. Which of the following actions should the second nurse take? A. Prepare a new syringe for the client who is preoperative. B. Give the prepared medication to the client who is preoperative. C. Help the client requesting assistance so the first nurse can give the prepared injection. D. Report this request to the charge nurse.

C. Help the client requesting assistance so the first nurse can give the prepared injection. The second nurse should help the other client so the first nurse can give the injection. The nurse who has prepared the injection is the only one who can safely identify what is in the syringe and be responsible for correctly administering the medication. Incorrect Answers: A. It is not necessary to waste the medication that is already prepared. B. A nurse should never give a medication that another nurse has prepared. The nurse administering the medication must prepare the medication in order to confirm what the syringe contains. D. This action is not necessary. /

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? A. Call the clients' family members to provide additional help with moving the clients. B. Ask clients who are able to ambulate to assist in moving the unstable clients. C. Instruct clients who are able to ambulate to leave. D. Direct staff members to close the doors and windows as each room is evacuated.

C. Instruct clients who are able to ambulate to leave. Clients who are able to ambulate should leave first in an evacuation process, as this quickly reduces the number of clients who require evacuation assistance. Incorrect Answers: A. Moving the clients is the responsibility of the facility's staff. Asking family members to come to the facility in an emergency puts them at risk and delays the evacuation process. B. Staff members should not ask clients to rescue unstable clients since this puts clients at great risk. In some situations, ambulatory clients can assist clients who are stable and in a wheelchair. The nurse should use critical thinking to determine the safety of this practice for some clients. D. Staff members should evacuate all clients prior to enacting containment measures. Taking the time to close doors and windows delays the evacuation process. ///

A nurse is caring for a client who is on bed rest and states, "I would prefer not to have all of the side rails on my bed raised." After assessing the client is safe without the four side rails raised, which of the following interventions should the nurse implement? A. Request a prescription from the provider to leave the client's side rails down. B. Inform the charge nurse of the client's feelings about the side rails. C. Leave the side rails down and document this decision as per the client's request. D. Arrange for the client to discuss these feelings with another client who uses side rails.

C. Leave the side rails down and document this decision as per the client's request. Raising all four side rails can be considered a form of restraint if they restrict the client's ability to get in and out of bed. This client is on bed rest and does not require that level of mobility; however, if the client expresses a wish for the rails to be down, the client's level of consciousness is not impaired, and there is no other specific safety hazard posed by lowering the side rails, the client's request should be respected. Incorrect Answers: A. Although there is no harm in informing the provider about this request, the nurse is able to act independently and lower the client's side rails after determining the client is safe and not at risk of falling out of bed. A prescription from the provider is not required for this action. B. The nurse is able to act independently and lower the client's side rails after determining the client is safe and not at risk of falling out of bed. The charge nurse does not need to be notified. It is the responsibility of the nurse caring for the client to address the client's feelings. D. Discussing this decision with another client does not address the problem and could be considered an invasion of both clients' privacy. //

A charge nurse overhears a unit nurse informing other unit nurses that the charge nurse is giving preferential treatment to the unit nurses on the night shift. Which of the following approaches by the charge nurse reflects an assertive response to resolve this conflict? A. Understanding that the unit nurse is misinformed and taking no action B. Assigning the unit nurse to work the night shift to facilitate direct experience with the night shift C. Meeting one-on-one with the unit nurse to discuss these concerns D. Confronting the unit nurse during the next unit meeting regarding this statement

C. Meeting one-on-one with the unit nurse to discuss these concerns The charge nurse should schedule a time to speak privately with the unit nurse about the situation. Assertive behavior involves discussing a situation directly with the person involved. Incorrect Answers: A. Avoidance by the charge nurse is a form of passive behavior, which does not solve the conflict. B. A unit nurse should not be reassigned to the night shift for the purpose of gaining experience on the night shift. The charge nurse should provide guidance in this situation with the unit nurse in another manner. D. The charge nurse should not confront the unit nurse about the situation in front of other staff members. This action can create further conflict between both parties and does not solve the present issue. /

A nurse is assisting with the informed consent process for a client who is scheduled for a below-the-knee amputation. The client asks the nurse, "Why are they making me have this surgery today? I don't understand why they are doing this." Which of the following actions should the nurse take? A. Complete an incident report. B. Administer an antianxiety medication. C. Notify the provider of the client's comments. D. Answer the client's questions and verify understanding.

C. Notify the provider of the client's comments. It is the nurse's responsibility to notify the provider if the client has questions or appears not to understand the procedure. The provider is responsible for providing clarification. Informed consent is a legal process by which a client gives written permission for a procedure or treatment. Incorrect Answers: A. The nurse should complete an incident report if the client's care does not meet facility and practice standards. The client's lack of knowledge is not an indication of substandard practice; it is an indication that more information is needed. The nurse should intervene to ensure the client receives the necessary information to allow informed consent. B. The client might be experiencing anxiety related to imminent surgery, but it is the nurse's responsibility to notify the provider if the client has questions or appears not to understand the procedure. A consent form must be signed freely by the client without threat or pressure and must be witnessed. A client who has been medicated with sedating medications or any other medications that can affect cognitive abilities should not sign a consent form. D. Explanation of a surgical procedure is part of the informed consent process, which does not fall within the nursing scope of practice. Informed consent is part of the provider-client relationship. Even though the nurse assumes responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent. The nurse's signature only indicates that the client voluntarily gave consent, the client's signature is authentic, and the client appears to be competent to give consent. //

A charge nurse is teaching a group of unit nurses about alternative restraints for clients who are confused and wandering. Which of the following pieces of information should the nurse include in the teaching? A. Distract the client by leaving on the television B. Plan to administer a sedative to the client C. Provide the client with a rocking chair D. Place full-length side rails on the client's bed

C. Provide the client with a rocking chair The nurse should advise providing the client with a rocking chair to expend some of the client's energy through rocking rather than walking, which leads to wandering. Incorrect Answers: A. The nurse should advise decreasing stimulation by reducing the noise level and dimming the lights. B. The nurse should advise limiting the administration of sedatives and psychotropic medications as an alternative restraint. The need for restraints can be related to over-medicating. D. The nurse should replace full-length side rails with half-length or three-quarter-length rails to reduce the risk of falling if the client has confusion. ///

A nurse is caring for a client who is a local public official. A newspaper reporter repeatedly phones the unit seeking information and states, "The public has a right to know the health status of elected officials." Which of the following actions should the nurse take? A. Acknowledge that the person is a client on the unit but give no specific details of the client's condition. B. Refer any calls directly to the client's room so that the client and her family can decide what to tell the press. C. Refer all media inquiries to the nursing supervisor. D. Hang up on media callers because nursing staff members are not required to speak to them.

C. Refer all media inquiries to the nursing supervisor. The HIPAA Privacy Rule prohibits disclosing client information to individuals who are not involved in care without the client's express consent. The reporter should be told that, due to confidentiality issues, no information can be given about any client. The nurse should refer the reporter to the nursing supervisor. Incorrect Answers: A. The HIPAA Privacy Rule prohibits disclosing client information to individuals who are not involved in care without the client's express consent. B. The nurse should not forward the call to the client's room because this will disclose the hospitalization. D. Hanging up on callers from the news media is unprofessional. The nurse should refer calls to the nursing supervisor. /

A nurse suspects that a coworker may be in an impaired state when providing care to clients. Which of the following actions should the nurse take? A. Ask other coworkers if they feel the same way. B. Speak directly with the impaired coworker. C. Report these observations to the nurse manager. D. Refuse to work with the impaired coworker.

C. Report these observations to the nurse manager. The nurse who observes an impaired coworker's performance should report this behavior to the nurse manager. If the coworker is found to be impaired, this action will initiate an appropriate intervention and support, and clients will be protected from the actions of an impaired coworker. Incorrect Answers: A. The nurse should not share this concern with other coworkers. If the concern is unfounded, the nurse will have disseminated false accusations to others, defaming the coworker's character. If it is true, this action can delay the initiation of an appropriate intervention and support for the impaired coworker. B. The nurse should not discuss this issue with the impaired coworker. If the concern is unfounded, the nurse could cause unnecessary conflict with the coworker. This action can also delay the initiation of an appropriate intervention and support for the impaired coworker. D. The nurse should not refuse to work with the impaired coworker, as this may cause conflict on the unit and create scheduling difficulties. This action can also delay the initiation of an appropriate intervention and support for the coworker if the coworker is actually impaired. /

An experienced nurse is serving as a mentor to a newly licensed nurse. Which of the following actions should the mentor take? A. Establish a set of goals for the newly licensed nurse to achieve. B. Establish a set timeframe with the newly licensed nurse for the mentorship process. C. Serve as a guide and teacher for the newly licensed nurse in an established relationship. D. Develop a program of study for the newly licensed nurse to follow.

C. Serve as a guide and teacher for the newly licensed nurse in an established relationship. A mentor establishes a nurturing relationship with a newly licensed nurse and is willing to invest time and resources to help this person develop as a nurse and an individual. Incorrect Answers: A. A mentor should assist the newly licensed nurse with setting and achieving realistic goals through support and guidance. B. A mentorship does not have a determined timeframe. This is a characteristic of a preceptor, who is often assigned by the facility for a set amount of time. D. Developing a program of study for a newly licensed nurse to follow is not the responsibility of a mentor. //

A nurse manager notes several recent conflicts among nurses on different shifts. Which of the following strategies should the nurse manager use to resolve these conflicts? A. Have the charge nurses for each shift get together and discuss the issues between shifts. B. Direct the nurses from each shift to discuss their issues and present solutions to the nurse manager. C. Set up a series of meetings for all staff members to attend to discuss issues. D. Remain uninvolved and allow the nurses from each shift to resolve the issues among themselves.

C. Set up a series of meetings for all staff members to attend to discuss issues. Through this approach, the nurse manager is using the conflict-resolution strategy of collaboration by encouraging all staff members associated with the conflict to communicate and work together to devise and implement win-win solutions. Incorrect Answers: A. This approach does not allow any of the staff members involved in the conflicts to contribute to solutions. B. This does not allow the nurse manager to participate in and facilitate the creation of win-win solutions. It only allows approval or disapproval after the staff members have spent time and energy devising potential solutions. D. This approach does not allow the nurse manager to facilitate the creation of win-win solutions. ///

A nurse is admitting a client who has active gastrointestinal bleeding. Which of the following tasks is appropriate for the nurse to delegate to an assistive personnel (AP)? A. Obtain the initial set of vital signs B. Listen for bowel sounds C. Show the client how to use the nurse call light D. Ask the client if he has any allergies

C. Show the client how to use the nurse call light The AP can show the client how to use the nurse call light, as this task does not require an assessment of the client first. Incorrect Answers: A. The nurse should not delegate obtaining the initial set of vital signs to an AP. The nurse must assess the client prior to delegating tasks to determine if the client is medically stable. B. This is an essential assessment for this client, but it is not within the AP's scope of practice. D. Asking the client if he has any allergies is a part of the admission assessment and is not within the AP's scope of practice. /

A charge nurse is observing a group of newly licensed nurses. Which of the following actions should the charge nurse report to the nurse manager as a violation of HIPAA? A. Assigning a client who requested a private room to a semi-private room due to unavailability B. Placing a client who is confused in restraints C. Talking about clients with other nurses in the cafeteria D. Wheeling a client who is wearing a sheet down the hall into the shower room

C. Talking about clients with other nurses in the cafeteria The nurse should not discuss information about clients—including their personal concerns, diagnoses, and treatments—with anyone who is not directly involved in the client's care. Doing so is a violation of HIPAA regulations. Nurses should take special care not to compromise this right by discussing client care in such places as elevators, restaurants, or other areas that are accessible to the public in which the discussion might be overheard. Incorrect Answers: A. While this is an unfortunate circumstance, it does not violate HIPAA regulations. If no private rooms are available, the nurse should assign the client to an available room and plan to move the client when a private room becomes available. B. Placing a client in restraints is not a violation of HIPAA regulations. However, this action could be considered false imprisonment if it is done without first taking other measures to ensure the client's safety. D. Although wheeling a client who is wearing only a sheet down the hall could be an invasion of personal privacy, it is not a HIPAA violation. The Privacy Rule associated with HIPAA addresses the use and distribution of personal client information. Nurses should take care to expose clients as little as possible to maintain their privacy. /

A nurse is caring for a client who is dying and unable to make decisions for himself. The client's adult children disagree about his code status. Which of the following sources should the nurse depend on for decisions regarding the client's end-of-life care? A. The client's oldest child B. The attending provider C. The client's health care proxy D. The facility's ethics committee

C. The client's health care proxy If the client cannot speak for himself, the nurse should follow the directions of the client's health care proxy, as this is the person the client chose to make decisions under these circumstances. Incorrect Answers: A. If the client does not have advance directives or has not named a health care proxy, the family may be asked to make end-of-life decisions. B. The attending provider may offer suggestions on end-of-life care, but the client or the client's health care proxy directs treatment. D. In the absence of advance directives, the facility's ethics committee may be called upon to intervene if a conflict occurs regarding end-of-life decisions. /

A home health care nurse is conducting a home hazard assessment. For which of the following findings should the nurse intervene? A. The client's hot water heater temperature is set to 46.1°C (115°F). B. There are 8 steps to enter the client's home. C. The client's household lamps have 40-watt light bulbs installed. D. The bathroom has a handheld shower attachment for bathing.

C. The client's household lamps have 40-watt light bulbs installed. The nurse needs to intervene for low-wattage light bulbs. Inadequate lighting increases the risk of falls and presents a safety hazard for the client. Incorrect Answers:A. The nurse does not need to intervene, as hot-water heater temperatures should be set to a maximum of 49°C (120°F). B. The nurse does not need to intervene for the steps leading into the client's home. The nurse should, however, assess any broken or loose steps and note the security of handrails on both sides of the stairway. D. The nurse does not need to intervene for a handheld shower attachment, as this will assist the client in bathing. The nurse should inspect the tub for a nonstick surface. ///

A nurse is following standard policy and procedure for reporting a client who has a communicable disease. Which of the following infections should the nurse plan to report to the CDC? A. Clostridioides difficile B. Candidiasis C. Vancomycin-resistant Staphylococcus aureus D. Trichomoniasis

C. Vancomycin-resistant Staphylococcus aureus The nurse should follow policy and procedure for reporting a client who has vancomycin-resistant S. aureus (a communicable disease) to the CDC. Incorrect Answers:A. The nurse should implement contact precautions for a client who has C. difficile; however, the nurse does not need to report this infection to the CDC. B. The nurse should contact the provider to prescribe medication to treat a candidiasis infection; however, the nurse does not need to report this infection to the CDC. D. The nurse should inform the client of the treatment guidelines for trichomoniasis that are available from the CDC and provide teaching about the client's prescription; however, trichomoniasis is not a communicable disease that needs to be reported to the CDC. ///

A nurse overhears two other nurses discussing a conflict they are having about who should complete certain client-care tasks. The nurses agree that they are tired of the conflict and will let the nurse manager decide who should complete the tasks. The nurse should identify this outcome as which of the following approaches to conflict management? A. Win-win B. Win-lose C. Win-yield D. Lose-lose

C. Win-yield A win-yield approach involves both parties no longer trying to resolve the conflict. Instead of taking the initiative to end the conflict, they agree to honor whatever the nurse manager decides. Incorrect Answers: A. A win-win strategy is a collaborative approach. There is no power struggle, and both parties work together for a positive outcome that meets a common goal. B. A win-lose strategy involves one party emerging victoriously and the other losing the struggle. If the losing party continues to pursue the situation, it becomes a competing strategy. D. A lose-lose strategy is also an avoidance approach. The two parties abandon the struggle and take no further action, but the conflict remains. In this outcome, no one wins. ///

A charge nurse finds an increased incidence of health-care-associated infections (HAIs) on a long-term care unit. Which priority action should the charge nurse take to address the problem? A. Monitor the staff's hand hygiene techniques B. Hold a mandatory in-service training session about hand hygiene and infection rates C. Require nurses to take an online course on HAIs D. Conduct a chart review to gather data about clients who developed HAIs

Conduct a chart review to gather data about clients who developed HAIs The charge nurse should first conduct a chart review or audit in order to gather data about the clients who developed infections. This information will provide the charge nurse with potential indicators or factors that resulted in the increased incidence of HAIs. Incorrect Answers: A. The charge nurse should monitor staff members' hand hygiene techniques on the unit to encourage proper hand hygiene; however, this is not the first priority. B. The charge nurse should hold a mandatory in-service training session about hand hygiene and infection rates after conducting a chart review. C. The charge nurse should require nurses to take an online course on HAIs to enhance their knowledge of hand hygiene and infection control after conducting a chart review. ///

A nurse case manager is planning a teaching session on use of critical pathways with a group of newly licensed nurses. The nurse should include which of the following in the teaching about critical pathways?

Critical pathways prevent unnecessary expense

A nurse case manager is planning a teaching session on use of critical pathways with a group of newly licensed nurses. The nurse should include which of the following in the teaching about critical pathways?

Critical pathways prevent unnecessary expense.

A nurse is teaching a group of newly licensed nurse managers about the principle of justice. Which of the following statements by a nurse manager indicates an understanding of this teaching? A. "I will refer an unhappy employee to the individual with whom a conflict arose." B. "I will allow staff members to schedule their birthday holidays on alternate days, as long as staffing levels are maintained." C. "I will encourage staff participation in choosing new telemetry monitors for the unit." D. "I will compose staff schedules so that each person works two holidays a year."

D. "I will compose staff schedules so that each person works two holidays a year." Justice means treating everyone fairly. By scheduling each person to work two holidays per year, the nurse manager is requiring staff members to work an equal share of holidays. Incorrect Answers: A. This is an example of the appropriate use of conflict management. By referring unhappy staff members to the individuals with whom they have conflicts, the nurse manager is encouraging individual problem-solving behaviors. B. This demonstrates the principle of autonomy. By allowing staff members to participate in scheduling while maintaining appropriate levels of staffing, the nurse manager is encouraging independent, professional behavior. C. This is an example of change theory. By allowing staff members to participate in decision-making for the unit, the nurse manager is encouraging staff input in the change process. /

A charge nurse is reviewing the Code of Ethics for Nurses during a staff meeting. Which of the following statements should the charge nurse include in the teaching? A. "The Code of Ethics for Nurses is legally binding." B. "The Code of Ethics for Nurses is mandatory for the practice of nursing." C. "The Code of Ethics for Nurses is a description of licensure requirements." D. "The Code of Ethics for Nurses is a guide for professional actions."

D. "The Code of Ethics for Nurses is a guide for professional actions." The American Nurses Association's Code of Ethics for Nurses is a guide for fulfilling nursing responsibilities in a way that reflects quality in nursing care and upholds the ethical obligations of the nursing profession. It provides a guide for professional actions. Incorrect Answers: A. The American Nurses Association's Code of Ethics is not a legally binding contract for nurses. B. The American Nurses Association's Code of Ethics for Nurses is not mandatory for the practice of nursing. C. The American Nurses Association's Code of Ethics for Nurses is not a description of requirements for nursing licensure. //

A nurse is providing discharge teaching about home safety to an older adult client and his family. Which of the following statements should the nurse include in the teaching? A. "You should set the water heater temperature to 125°F." B. "You should grasp the cord when unplugging items." C. "You should use a gas stove for cooking." D. "You should install a handrail on at least one side of the stairs."

D. "You should install a handrail on at least one side of the stairs." The nurse should instruct the client and his family to install a handrail on at least one side of the stairs to decrease the potential risk of falls. Incorrect Answers: A. The nurse should instruct the client to set the hot water thermostat to 48.9°C (120°F) or lower to prevent scalding and burns. B. The nurse should instruct the client to grasp the plug when unplugging items, not the cord. C. The nurse should instruct the client to use microwave or electric toaster ovens instead of open flames and burners. Gas stoves are a potential fire risk. /

A charge nurse on a pediatric unit is delegating tasks to an assistive personnel (AP) who is pregnant and reports that she is unsure of her immune status. Which of the following clients should the charge nurse assign to the AP? A. A 9-year-old child who has fifth disease B. A 4-year-old child who has varicella (chicken pox) C. A 6-year-old child who has rubella D. A 2-year-old child who has impetigo contagiosa (impetigo)

D. A 2-year-old child who has impetigo contagiosa (impetigo) This is a safe assignment. If the AP practices universal precautions, there is no risk of contracting impetigo. Impetigo is a superficial skin infection caused by either Staphylococcus or Streptococcus. Incorrect Answers:A. If the AP has never had fifth disease, the chance of contracting it is significant. Erythema infectiosum is a communicable disease and has been associated with early fetal loss. There is no immunization for fifth disease. B. If the AP has never had varicella or been immunized against it, the chance of contracting it is significant. Varicella is a communicable disease and a known teratogen. C. If the AP has never had rubella or been immunized against it, the chance of contracting it is significant. Rubella is a communicable disease and a known teratogen. //

A charge nurse receives a call from the nursing supervisor about an explosion at a local factory and an urgent need for facility beds for newly admitted clients. Which of the following clients should the nurse recommend for discharge? A. A 60-year-old client with type 2 diabetes mellitus who was admitted 48 hr ago with uncontrolled glucose levels B. A 58-year-old client who is 12 hr postoperative following a total knee arthroplasty C. An 80-year-old client admitted 24 hr ago for vomiting and dehydration D. A 44-year-old client with asthma who was admitted for carpal tunnel surgery

D. A 44-year-old client with asthma who was admitted for carpal tunnel surgery A client who is admitted for carpal tunnel surgery is stable and having an elective procedure. Therefore, the nurse should recommend this client for discharge. Incorrect Answers: A. A client who was admitted 48 hours ago with uncontrolled glucose levels is considered unstable. The nurse should not recommend this client for discharge. B. A client who is 12 hours postoperative following a total knee arthroplasty is considered unstable. The nurse should not recommend this client for discharge. C. A client who was admitted 24 hours ago for vomiting and dehydration is considered unstable. The nurse should not recommend this client for discharge.

A nurse on a medical-surgical unit is planning the care of assigned clients. Which of the following clients should the nurse attend to first? A. A client who is newly admitted and is scheduled for indwelling urinary catheter insertion B. A client who has kidney stones and reports flank pain of 6 on a pain scale of 0-10 C. A client diagnosed with early stage chronic kidney disease with a serum creatinine level of 2.0 mg/dL D. A client who has a cast newly applied on the forearm and reports tingling of the fingers

D. A client who has a cast newly applied on the forearm and reports tingling of the fingers When using the airway, breathing, circulation (ABC) approach to client care, the nurse should first assess the client who has a newly applied cast on the forearm and reports tingling of the fingers. Tingling, numbness, pallor, paresthesia, and pain are clinical manifestations associated with compartment syndrome, a serious development in which increased tissue pressure in a confined anatomical space reduces blood flow, leading to ischemia, dysfunction, and eventual necrosis. The nurse should report this finding to the provider immediately. Incorrect Answers: A. The nurse should assess a client who is newly admitted and is scheduled to have an indwelling urinary catheter to empty the bladder of urine; however, there is another client the nurse should attend to first. B. The nurse should assess a client who has kidney stones and reports a flank pain of 6 on a pain scale of 0-10 to address and treat the client's pain; however, there is another client the nurse should attend to first. C. The nurse should assess a client diagnosed early with early stage chronic kidney disease who has a serum creatinine of 2.0 mg/dL to determine kidney function; however, there is another client the nurse should attend to first. /

A nurse is selecting clients for discharge following an environmental disaster. Which of the following clients should the nurse select? A. A client who had a cast removal due to compartment syndrome B. A client who is scheduled for dialysis and has a potassium level of 6.2 mEq/L C. A client who has type 1 diabetes mellitus and a blood glucose of 320 mg/dL D. A client who is 1 day postoperative following an inguinal hernia repair

D. A client who is 1 day postoperative following an inguinal hernia repair The nurse should select the client who had an inguinal hernia repair for discharge because this client is stable. Incorrect Answers:A. A client who has compartment syndrome needs continuous monitoring of the affected extremity. B. A client who is hyperkalemic and in need of dialysis may experience dysrhythmic complications from the electrolyte imbalance. C. A client who has type 1 diabetes mellitus and a blood glucose of 320 mg/dL will need to be monitored to track blood glucose and the client's response to insulin therapy. ///

A nurse is prioritizing care for a group of clients. The nurse should plan to attend to which of the following clients first? A. A client who requires a sterile dressing change B. A client who requires gastrostomy tube feeding C. A client who requires urinary catheter care D. A client who requires endotracheal suctioning

D. A client who requires endotracheal suctioning When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should attend to a client who requires endotracheal suctioning first. Without this intervention, mucus and secretions could accumulate and block the client's airway. Incorrect Answers: A. The nurse should perform a sterile dressing change to evaluate wound healing and help prevent infection; however, another client is the nurse's priority. B. The nurse should administer gastrostomy tube feeding to support the client's nutrition and hydration; however, another client is the nurse's priority. C. The nurse should perform urinary catheter care to help prevent a catheter-related urinary tract infection; however, another client is the nurse's priority. /

A nurse manager is observing the staff members working on her unit. Which of the following actions should the nurse manager recognize as an example of paternalism? A. A nurse asking to care for an older adult client every day who reminds the nurse of a favorite grandparent B. A male nurse caring for an adolescent male client because the client is uncomfortable around female nurses C. A middle-aged adult assistive personnel (AP) mentoring a younger less-experienced AP on the unit D. A nurse practitioner withholding information from a client who is dying to avoid causing the client distress

D. A nurse practitioner withholding information from a client who is dying to avoid causing the client distress Paternalism is a type of relationship between clients and health care providers in which the health care providers believe they know what is best for the clients. In this example, the nurse practitioner withholds information so as not to cause the client distress. This practitioner is making the decision for the client and denying the client the right to be informed. Incorrect Answers: A. B. In this example, the nurse is appropriately caring for the client. C. In this example, the AP is taking appropriate action. ///

A nurse is caring for a client who refuses to take her prescribed oral medication. The nurse states, "If you don't take this pill, I'm going to give you the medication by injection." Which of the following types of tort has the nurse committed? A. Slander B. Battery C. Negligence D. Assault

D. Assault The nurse has committed the tort of assault, which is an attempt or threat to touch another person unjustifiably. The nurse threatening to administer an IM injection to the client if she does not take her medication orally is a form of assault. Incorrect Answers: A. Slander, or spoken defamation of character, refers to a false statement by one person that can damage another person's reputation, casting a negative light on that person's character. B. Battery refers to the willful touching of another person in a way that may or may not cause harm. An example of battery is touching a client without permission in a manner that causes harm or creates embarrassment. C. Negligence is the failure to provide the expected standard of care. /

An RN and a licensed practical nurse (LPN) are caring for a client who has a small bowel obstruction and is NPO with a nasogastric (NG) tube set to continuous suction. Which of the following tasks should the RN perform? A. Obtain daily weight B. Inspect the client's oral cavity for dryness hourly C. Measure and record the NG tube output every 4 hours D. Assess for bowel sounds every 2 hours

D. Assess for bowel sounds every 2 hours Assessments are within the scope of practice for the RN only. While the LPN can also auscultate the client's abdomen for the presence of sounds, only the RN is qualified to evaluate the sounds and qualify them as hypoactive, normal, or hyperactive. Incorrect Answers: A. Obtaining a daily weight is within the scope of practice of an LPN. While the RN could also perform this task, it should be delegated to an LPN so that the RN is available to perform other tasks. B. Oral care is considered part of routine hygiene and includes observing the membranes of the mouth for dryness. It is within the scope of practice for the LPN. While the RN could also perform this task, it should be delegated to an LPN so the RN is available to perform other tasks. //

A health care facility's leadership team is implementing a new computerized charting system. When preparing for the implementation date, which of the following actions should the nurse manager take first? A. Discuss with the charge nurses their responsibility in implementing the change. B. Post a sign-up sheet for in-service training sessions about the new system. C. Ask informal leaders to participate in the early implementation process. D. Collect the staff members' input about planning and implementing the change.

D. Collect the staff members' input about planning and implementing the change. The nurse manager should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he/she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse manager should first assess the situation by collecting the staff members' input and collaborating about implementing the change smoothly and efficiently. Incorrect Answers: A. The nurse manager should discuss the importance of the charge nurses' role in implementing the change; however, there is another action the nurse manager should take first. B. Educating staff members about the change will promote understanding and implementation of the new system; however, there is another action the nurse manager should take first. C. The nurse manager should enlist informal leaders in promoting the change; however, there is another action the nurse manager should take first. //

A nurse is planning to perform a negotiation to manage a conflict between himself and another staff member. Which of the following actions should the nurse plan to take? A. Continue the negotiation process until all parties agree on a settlement. B. Establish equality in the concessions that each party makes. C. Make as many concessions as needed to make everyone happy. D. Create a solution in which all parties are satisfied.

D. Create a solution in which all parties are satisfied. The goal of negotiation is to create a win-win situation in which all parties are satisfied with the results. Both parties involved in the conflict should be willing to make concessions. Incorrect Answers: A. It is often necessary to take a break from the negotiation process if anyone becomes angry or tired. B. Equality is not necessary for concessions made by the parties during a negotiation; often, this is unrealistic or impossible. C. Prior to the negotiation, the nurse should determine his starting point, bottom line, and which trade-offs he is willing to make. The nurse should be assertive with his requests without becoming aggressive. //

A nurse is caring for a postoperative client who has an Hgb of 8.0 g/dL. The nurse delegates the administration of a unit of packed RBCs to a nurse floating from a psychiatric unit who is unfamiliar with blood administration. Which of the following actions should the float nurse take? A. Call the provider to clarify the prescription for administering the unit of packed RBCs. B. Hang the unit of blood if the charge nurse agrees to be a resource. C. Question the nurse regarding this prescription due to the client's reported Hgb level. D. Decline to hang the blood.

D. Decline to hang the blood. The nurse has a legal duty to decline tasks that cannot be performed safely and competently. A float nurse from a psychiatric unit would not be familiar with the current policy regarding blood administration, and this nurse has limited experience with this procedure. Therefore, the task should be assigned to another nurse. Incorrect Answers: A. The nurse does not need to call the provider to clarify the prescription, which is appropriate for a client with this hemoglobin level. B. The nurse should accept tasks that can be performed safely and competently. C. The client's Hgb is below the expected reference range, and transfusions are appropriate. //

Based on recommendations following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff nurses on the unit is resistant to the change, and the nurse manager notes that this nurse does not deliver care according to the new policy. Which of the following actions should the nurse manager take? A. Explain the disciplinary consequences of refusing to implement the new policy. B. Reinforce with the staff nurse the importance of implementing the policy change. C. Ignore the staff nurse's resistance and allow peer pressure to facilitate the change. D. Encourage the staff nurse to verbalize reasons for resisting the change.

D. Encourage the staff nurse to verbalize reasons for resisting the change. The nurse manager should realize that if the nurses who must implement the change are not invested in the change process, resistance is likely. This is especially problematic when the change is unplanned or imposed by outside forces. The resistant staff nurse has likely rejected the change due to prior habits, fear of the unknown, and lack of time to learn something new. A meeting between the nurse manager and the staff nurse will provide an open forum for the staff nurse to verbalize the reasons for reluctance in adopting the new policy. Incorrect Answers: A. Taking an authoritative approach and threatening the nurse through the use of coercive power are not appropriate actions. B. Reinforcing the importance of the new policy with the staff nurse will not produce a behavior change, as this approach has already proven unsuccessful. C. Adopting a laissez-faire attitude toward the staff nurse in hopes that others will take responsibility for the nurse's behavior is not an appropriate action manager and will allow the behavior to continue indefinitely. /

A nurse is creating a plan of care for a client who adheres to Kosher dietary laws. Which of the following food selections should the nurse recommend? A. Baked pork chop B. Cheeseburger C. Ham and cheese omelet D. Grilled salmon

D. Grilled salmon The nurse should recommend grilled salmon for a client who observes Kosher dietary laws. Grilled salmon is a fish with fins and scales, which can be consumed. Seafood with shells, such as lobster or crab, is prohibited. Incorrect Answers: A. A baked pork chop is a source of pork, which is prohibited by Kosher dietary laws. B. A cheeseburger contains both meat and dairy products, which may not be eaten at the same time and is prohibited by Kosher dietary laws. C. A ham and cheese omelet contains pork, which is prohibited by Kosher dietary laws. /

A nurse manager observes a nurse entering the room of a client who is on contact precautions without donning personal protective equipment (PPE). Which of the following is the priority action for the nurse manager to take? A. Speak with the nurse in a private location. B. Complete an incident report. C. Review competencies with the staff members regarding PPE. D. Have the nurse exit the room and don proper PPE.

D. Have the nurse exit the room and don proper PPE. The nurse manager should apply the safety and risk-reduction priority-setting framework when intervening with the nurse. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse manager should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse manager should first ensure the safety of the staff and clients by having the nurse exit the room and don proper PPE before re-entering the room. Incorrect Answers:A. The nurse manager should speak with the nurse in a private location to discuss the safety issues of not donning PPE and the risk involved for both the staff and clients; however, this is not the priority action for the nurse manager to take. B. The nurse manager should complete and submit an incident report to risk management when there is an error in technique or procedure; however, this is not the priority action for the nurse manager to take. C. The nurse manager should review competencies regarding PPE with the staff to ensure proper use of PPE and the safety of staff members and clients; however, this is not the priority action for the nurse manager to take. /

A nurse is having difficulty completing care and documentation without staying past the end of the shift. The nurse manager suggests focusing on time-management skills. Which of the following strategies should the nurse plan to use? A. Practice multitasking throughout the shift B. Postpone completing documentation until the end of the shift C. Occasionally skip a break time D. Identify tasks in order of their priority

D. Identify tasks in order of their priority Prioritizing is an important time-management strategy. The nurse should prioritize each client's needs and tasks and attend to the highest priority client first. Incorrect Answers: A. When possible, the nurse should complete each task for a client before moving on to the next client. B. The nurse should document nursing actions as soon as possible after performing them. Delaying documentation can lead to inaccuracies and incomplete documentation. C. The nurse should always take scheduled breaks to refresh mentally and physically. /

A nurse is completing an incident report after administering an incorrect dose of medication to a client, even though the client experienced no ill effects from the error. What is the purpose of completing the incident report? A. Alerting the facility administration of a possible litigation situation B. Tracking employee performance for possible disciplinary action C. Providing a detailed report of the occurrence for the client's family D. Identifying situations that contribute to the occurrence of medication errors

D. Identifying situations that contribute to the occurrence of medication errors The purpose of completing incident reports is to identify factors that contribute to the occurrence of the problem. This is one aspect of quality-improvement efforts in health care facilities. Incorrect Answers:A. Incident reports are not completed to alert the facility administration of possible litigation situations. B. Using incident reports as a means for employee discipline will hinder the reporting of problems and inhibit the finding of solutions to improve the quality of client care. C. An incident report should not be given to the client's family as a means of providing detailed information about the error. /

A nurse manager is implementing a team nursing approach on his unit, hiring licensed practical nurses (LPNs) and assistive personnel (AP) as additional staff. Which of the following actions should the nurse manager take to facilitate acceptance of this change? A. Develop a plan for the change and present it during a staff meeting. B. Explain that this change is a request from the administration and will be carried out. C. Hire new LPNs and APs and gradually integrate them into the staff. D. Introduce the new approach and facilitate the development of a task force to plan implementation.

D. Introduce the new approach and facilitate the development of a task force to plan implementation. This appropriate approach involves the staff in the planning and will give them a feeling of control over their practice and enhance acceptance of the change. Incorrect Answers: A. This approach to staffing change is authoritarian in nature. Involvement of staff in facilitating the change is more democratic and will enhance acceptance. B. This approach will make nurses feel powerless and resentful. Additionally, removing staff from involvement in the change process will decrease acceptance of the change. C. This approach is indirect and may precipitate feelings of mistrust. Role conflict may develop if the introduction of the new nurses and their roles in the unit are not discussed first with the existing staff. ///

A new nurse manager on a busy oncology unit keeps her door closed when she is in the office and does not offer to help resolve daily staffing issues. Which of the following types of leadership behavior is this nurse manager displaying? A. Transformational B. Democratic C. Autocratic D. Laissez-faire

D. Laissez-faire This nurse manager is a laissez-faire leader, providing little support or guidance. The leader's activity is minimal and contributes to reduced staff efficiency. Incorrect Answers: A. A transformational leader motivates employees by creating a work environment in which the goals of the leader are shared by the employees. This common perception of united goals allows the manager to provide opportunities for employees to feel like they are contributing on a higher level, as well as developing personal goals that can be achieved by opportunities created or supported by the manager. B. A democratic leader acts as a facilitator and resource person and maintains a moderate degree of control among group members. C. An autocratic leader is controlling and makes all of the decisions. This type of leader maintains a high degree of control and allows little freedom among group members. //

A nurse is documenting data about a client at a computer terminal in the nurses' station when he has to leave the area to assist another client. Which of the following actions should the nurse take? A. Turn the computer monitor away from the view of others. B. Ask the unit clerk to make sure no one else uses that computer. C. Turn off the monitor so the computer will log off automatically. D. Log off the computer before leaving the nurses' station.

D. Log off the computer before leaving the nurses' station. To ensure no one else has access to the client's protected health information, the nurse should log off the computer terminal and turn off the monitor. Incorrect Answers:A. This action poses a risk for a breach of confidentiality because other staff members might use the computer and see the client's protected health information. B. This action poses a risk for a breach of confidentiality. The unit clerk might see the client's protected health information, or the unit clerk might have to leave the area while the client's information is visible on the computer screen. C. This action poses a risk for a breach of confidentiality because another staff member might access the computer before the nurse logs off and see the client's protected health information. /

A nurse enters a client's room and discovers a small fire in a trash can. Which of the following actions should the nurse take first? A. Place moist towels or blankets at the threshold of the door of the room with the fire. B. Close fire doors and doors to client rooms. C. Pull the fire alarm and notify the hospital operator. D. Move the client out of the room.

D. Move the client out of the room. The nurse should apply the safety and risk-reduction priority-setting framework when responding to a fire. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, to ensure the safety of the client, the nurse should move the client out of the room. Incorrect Answers:A. The nurse should place moist towels or blankets at the threshold of the door where the smoke is coming from to help contain the fire and prevent the smoke and fumes from entering other areas; however, a different action is the priority. B. The nurse should close fire doors to prevent the spread of a fire to other areas of the facility and close the doors of client rooms to prevent smoke and fumes from entering; however, a different action is the priority. C. The nurse should pull the fire alarm and alert the facility operator to notify the appropriate fire-fighting individuals; however, a different action is the priority. /

A nurse is preparing to give a change-of-shift report to the oncoming nurse. Which of the following pieces of information should the nurse include? A. Routine care procedures for the client B. Biographical information C. Assumptions regarding relationships among the client's family members D. Objective measurements about the client's condition

D. Objective measurements about the client's condition The nurse should include objective observations and measurements about the client's condition in the report. Incorrect Answers: A. The nurse should not include routine care procedures for the client in the report. B. The nurse should not include biographical information for the client in the report since this information is already available. C. The nurse should not include assumptions regarding relationships among the client's family members in the report. /

A nurse is planning care for a client who has aphasia following a stroke. Which of the following actions should the nurse take? A. Avoid the use of facial gestures when speaking to the client. B. Speak to the client in a loud tone of voice. C. Use child-like phrases to help the client understand commands. D. Offer pictures for the client to point to as an alternative form of communication.

D. Offer pictures for the client to point to as an alternative form of communication. The nurse should use alternative forms of communication as needed with the client such as offering pictures the client can point to or a communication board. Incorrect Answers: A. The nurse should speak slowly and use short, simple statements with facial gestures to give additional cues about the information and facilitate client comprehension. B. The nurse does not need to speak in a loud tone of voice since the client does not have a hearing deficit. C. The nurse should avoid patronizing the client or using childish phrases /

A nurse is receiving report on a client who has C-Diff and is being transferred from another unit. Which of the following precautions should the nurse take? A. Place the client in a negative-airflow room. B. Clean the client's room with antibacterial disinfectant. C. Wear a mask when entering the client's room. D. Perform hand hygiene with nonantimicrobial soap and water after client care.

D. Perform hand hygiene with nonantimicrobial soap and water after client care. The nurse should perform hand hygiene with nonantimicrobial soap and water after providing care for a client who has C-diff. This spore-forming organism is resistant to alcohol-based soaps and sanitizers. Incorrect Answers: A. The nurse should place the client in a private room to isolate the infection. If a private room is not available, the nurse should place the client in a room with another client who has the same infection. B. The nurse should clean the client's room with a bleach solution. C-diff is a spore-forming organism that can remain on surfaces if not treated with a bleach solution. C. The nurse does not need to wear a mask when entering the client's room because C-diff is transmitted by contact. The nurse should wear a mask when a client is in droplet or airborne isolation. //

A nurse is caring for a client who has recently been prescribed lithium carbonate. Which of the following assessment findings is the priority for this client? A. Fine hand tremors B. Weight gain of 2.7 kg (6 lb) C. Report of nausea D. Poor motor coordination

D. Poor motor coordination When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is poor motor coordination, which is an advanced manifestation of lithium carbonate toxicity. The nurse should hold the client's medication and notify the provider. Incorrect Answers: A. Hand tremors are an expected finding for a client who has recently been prescribed lithium carbonate, and the tremors may continue for a few weeks before subsiding. Therefore, another finding is the nurse's priority. B. Weight gain is an expected finding for a client who has recently been prescribed lithium carbonate and can be addressed using diet and exercise. Therefore, another finding is the nurse's priority. C. Nausea is an expected finding for a client who has recently been prescribed lithium carbonate, and it may continue for a few weeks before subsiding. Therefore, another finding is the nurse's priority. ///

While participating in a continuous quality-improvement program, a nurse is reviewing medical records to determine the time of first postoperative ambulation of clients who had abdominal surgery. In which type of quality audit is the nurse participating? A. Outcome B. Structure C. Strategic planning D. Process

D. Process A process audit measures the interventions used to facilitate expected and desired outcomes for clients. Early ambulation is essential for the prevention of postoperative complications. Incorrect Answers: A. An outcome audit evaluates how the client's health status changed as a result of an intervention. B. A structure audit evaluates the relationship between quality care and appropriate structure and includes inputs such as the environment in which care is delivered. C. Strategic planning is done as a part of the planning process. It typically examines the purpose, mission, philosophy, and goals of an organization. ///

A nurse manager is orientating newly licensed nurses to a facility and is emphasizing the importance of practicing within standards of care. To which of the following legal concepts is the nurse manager referring? A. Punitive damages B. Intentional torts C. Good Samaritan laws D. Professional negligence

D. Professional negligence Standards of care establish safe nursing practices. Professional negligence occurs when a nurse is acting in a manner that a reasonable and prudent nurse would not, resulting in unsafe care. Professional negligence constitutes malpractice. Incorrect Answers:A. Punitive damages are a form of financial compensation awarded to a client who has been injured. The compensation goes beyond the costs of the loss and is intended as a punishment to the party who caused the damage. B. Torts are wrongdoings committed against a person. An intentional tort is an act that violates the rights of another, such as assault, battery, false imprisonment, and invasion of privacy. C. Good Samaritan laws apply to health care workers and sometimes non-medical professionals who attempt to aid a person in an emergency outside of a medical setting. These laws protect the health care worker from liability as long as the scope of practice is not exceeded. //

A nurse is discussing palliative care with the family of a client who is terminally ill. Which of the following should the nurse include as the purpose of palliative care? A. Curing the disease B. Producing remission C. Hastening death D. Providing comfort measures

D. Providing comfort measures Palliative care is an approach to care that promotes comfort for a client who has a terminal diagnosis and is not receiving aggressive therapy. Palliative care focuses on managing manifestations of the disease, not on curing the disease. Incorrect Answers:A. Curing the disease is only possible when specific treatment is available. Palliative care is only an option when there is no possibility of a cure or when a client with a terminal disease has refused treatment. B. If a remission is possible with treatment, this should be offered to the client before palliative care. Palliative care is only an option when there is no possibility of a remission or when a client who has a terminal disease has refused treatment. C. Palliative care is not intended to prolong or hasten death. Instead, it seeks to provide comfort for a client who is terminally ill. /

A nurse is tracking the outcomes of clients on the unit who have received postoperative pain management. This activity demonstrates which of the following competencies of the Quality and Safety Education for Nurses (QSEN) initiative? A. Safety B. Informatics C. Patient-centered care D. Quality improvement

D. Quality improvement This QSEN competency involves using data to track outcomes with the goal of devising processes to improve clients' outcomes. Incorrect Answers: A. This QSEN competency involves using national safety guidelines and goals to provide safe client care. B. This QSEN competency involves navigating clients' electronic health records and using technology effectively to manage client care. C. This QSEN competency involves determining clients' needs, preferences, and values and providing care that addresses these parameters. ///

A nurse is planning care for a client who is newly admitted to the medical unit. Which of the following health care team members should the nurse plan to consult with regarding the benefit of chest physiotherapy for this client? A. Physical therapist B. Occupational therapist C. Speech-language pathologist D. Respiratory therapist

D. Respiratory therapist The nurse should collaborate with the respiratory therapist and the client's provider to determine if chest physiotherapy (CPT) could benefit the client. A complete respiratory assessment is necessary to confirm the need for CPT. Incorrect Answers: A. The nurse should consult a physical therapist for clients who need assistance related to musculoskeletal problems. B. The nurse should consult an occupational therapist for clients who have impaired function of the skills necessary to complete ADLs. C. The nurse should consult a speech-language pathologist for issues like difficulty swallowing or for clients who are communicatively impaired. /

A nurse manager notes that several staff members are late in completing an annual mandatory educational session about extremity restraint safety. Which of the following actions should the nurse manager plan to take? A. Make a general announcement at the next staff meeting asking all employees to check their adherence to the requirement. B. Post a list in the employees' break room naming those who are non-adherent and the date by which they must complete the requirement. C. Schedule a disciplinary conference with each of the non-adherent employees. D. Send an email to each non-adherent employee that includes a link to upcoming educational sessions.

D. Send an email to each non-adherent employee that includes a link to upcoming educational sessions. Email provides a simple yet efficient way for the nurse manager to inform non-adherent employees about options for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the email facilitates adherence by helping each employee identify an upcoming session that coordinates with his/her work schedule. Incorrect Answers: A. This action does not address the specific employees who are non-adherent. B. The employees might interpret this action as punitive and embarrassing for those who are non-adherent. C. The nurse manager should delay scheduling a disciplinary conference unless the employees do not demonstrate the desired behavior after less punitive actions are taken. ///

A nurse is reviewing laboratory results for a client who is at 12 weeks gestation. Which of the following findings should the nurse report to the provider? A. Hgb 12 g/dL B. WBC 15,000/mm^3 C. Fasting blood glucose 80 mg/dL D. Serum creatinine 0.4 mg/dL

D. Serum creatinine 0.4 mg/dL This value is below the expected reference range for a client who is pregnant. The nurse should report this value to the provider. The other values are within the expected reference range for a client who is pregnant. ///

A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse direct the AP to perform first? A. Change the transparent dressing on a client who has a stage 2 pressure ulcer B. Bring a pitcher of fresh water to a client who has just had a lumbar puncture C. Transport a client to the radiology department for a routine chest X-ray D. Take an arterial blood gas specimen to the laboratory

D. Take an arterial blood gas specimen to the laboratory Arterial blood gas specimens are placed on ice and must be transported to the laboratory immediately to prevent degradation of the sample. Since this task needs to be done within a specified timeframe, it is the first task the AP should perform. Incorrect Answers: A. This type of dressing change rarely requires a strict schedule and can be done when time allows. B. While a client who has just had a lumbar puncture will need to force fluids to help prevent a post-lumbar puncture headache, this is not the first task the AP should perform. C. A routine chest X-ray can be delayed. If the client was experiencing respiratory difficulty, then the chest X-ray would be a higher priority. //

A charge nurse is planning a performance appraisal for a newly hired assistive personnel (AP). Which of the following factors should the charge nurse take into consideration when planning a performance appraisal interview for the AP? A. The performance appraisal interview should be friendly and informal. B. Aside from the charge nurse, no one should have input regarding the AP's appraisal. C. A nursing administrator who does not know the AP should conduct the interview to promote fairness. D. The AP should have a copy of the performance standards before the appraisal interview.

D. The AP should have a copy of the performance standards before the appraisal interview. The AP should have a copy of the performance standards prior to the interview in order to indicate what his/her performance is being measured against. Incorrect Answers: A. Performance appraisal interviews should be formalized and consistent in order to decrease the possibility of subjectivity. B. Other sources, such as coworkers and client evaluations, should be considered when planning the appraisal interview. C. The appraisal will be more effective if the interview is conducted by a charge nurse who the AP knows and trusts. /

A nurse is teaching a group of unit nurses about the Health Insurance Portability and Accountability Act (HIPAA). Which of the following pieces of information should the nurse include in the teaching? A. The Privacy Rule limits the client's rights to personal health information. B. The electronic transfer of information allows each provider to use his/her own electronic format for claim transactions. C. Standardized numbers can have a varied format for identifying health plans. D. The Security Rule provides a uniform level of security to protect client records.

D. The Security Rule provides a uniform level of security to protect client records. The security rule provides a uniform level of protection of clients' records, which includes maintaining the confidentiality, integrity, and availability of the client's records. Incorrect Answers:A. The privacy rule gives the client the right to access personal health information and medical records. B. Providers use a standardized transfer process when transferring electronic information among health care organizations. C. A standard format is used for standardized numbers, which identify the client's health plans, providers, and employers (e.g. an employer's tax identification number). /

A nurse is working with an assistive personnel (AP) in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks? A. Whether the AP has consented to the performance of delegated tasks B. The client's willingness to consent to care from the AP C. Whether the task can be more efficiently completed by the nurse D. The degree of supervision that the AP will require to complete the task

D. The degree of supervision that the AP will require to complete the task Successful delegation involves assigning the right task to the right person under the right circumstances. The person who will perform the task must be given adequate direction and specification regarding the amount of supervision that will be provided. The right communication of expectations and the right feedback about performance must also be supplied. Incorrect Answers: A. The nurse does not have to obtain consent from the AP when delegating tasks within the scope of practice and job description for APs. B. Tasks that can be delegated to an AP do not require the client's consent. C. One of the barriers to successful delegation is the belief that no one can do a task as efficiently and effectively as the nurse. Due to the time constraints on nurses, tasks that can be done by an AP should be duly delegated. //

A nurse is teaching a newly licensed nurse about the informed consent process for a client who is scheduled for a surgical procedure. Which of the following pieces of information should the nurse include in the teaching? A. Clerical staff in the facility can witness the signature of a client on a consent form. B. The nurse caring for a client is responsible for explaining the procedure. C. A family member should be present when a client signs a consent form. D. The person who will perform the procedure is responsible for obtaining informed consent.

D. The person who will perform the procedure is responsible for obtaining informed consent. The person performing the procedure is legally responsible for obtaining informed consent. Informed consent includes telling the client about the risks and benefits of the procedure, alternative treatments available, and possible outcomes if the procedure is not performed. Incorrect Answers: A. Clerical staff cannot witness a client's signature on a consent form because they cannot ensure that the consent is informed. B. The nurse caring for the client is not responsible for explaining the procedure. Verifying that a signed consent form is in the medical record before the procedure and witnessing the client's signature are responsibilities of the assigned nurse. C. A family member does not need to be present for a client to provide consent for a surgical procedure. /

A nurse on a medical-surgical unit is delegating tasks to nursing team members. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Instructing a client how to use a glucometer B. Instilling lubricating eye drops for a client C. Evaluating the effectiveness of a client's pain medication D. Transferring a client who is postoperative from a bed to a chair

D. Transferring a client who is postoperative from a bed to a chair Tasks that a nurse should delegate to an AP include transfers, ambulation, vital-sign measurement, and other simple procedures that do not involve assessment or teaching. Incorrect Answers: A. The nurse should not delegate tasks that involve teaching to an AP. B. The nurse should not delegate tasks that involve medication administration to an AP. C. The nurse should not delegate tasks that involve assessment to an AP. /

A nurse is ambulating a client who has an IV with an infusion pump. After the nurse returns the client to his room and plugs in the infusion pump, the client reports a slight tingling in his hand. Which of the following actions should the nurse take? A. Plug the pump into a different outlet. B. Place a service tag on the pump for a routine inspection. C. Unplug the pump and plug it back into the same outlet to see if the sensation of tingling is repeated. D. Turn off the pump.

D. Turn off the pump. The pump must be turned off immediately to protect the client and the nurse from the risk of electrical injury and fire. The nurse should consider any electrical equipment that shows a sign of malfunction to be unsafe and place it out of service until it can be checked by the facility's maintenance department. Incorrect Answers:A. Unplugging the pump and plugging it into another outlet increases the risk of electrocution or fire. This is not an appropriate action. B. Placing a service tag on the pump for routine inspection is not an appropriate action. C. Unplugging the pump and plugging it in again increases the risk of electrocution or fire for the client and the nurse. This is not an appropriate action. /

A nurse is reviewing informed consent with a client who is scheduled for a cardiac catheterization. Which of the following is the responsibility of the nurse? A. Explaining the procedure to the client B. Offering alternative treatments C. Informing the client of the consequences of refusing the procedure D. Verifying the client's understanding of the procedure being performed

D. Verifying the client's understanding of the procedure being performed The nurse must verify that the client understands and can describe the procedure being performed. Incorrect Answers: A. It is the responsibility of the provider to explain the risks and benefits of the procedure to the client. B. It is the responsibility of the provider to offer and explain alternative treatments. C. The nurse should notify the provider if the client has refused the procedure. It is the responsibility of the provider to review the consequences of refusing the procedure with the client. /

A charge nurse is performing chart reviews on infection control precautions implemented by nursing personnel during the admission of clients to the unit. Which of the following is an appropriate infection control precaution?

Droplet precautions for a client who has meningococcal pneumonia

An older adult client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a PICC line. Which of the following actions should the case manager perform prior to discharge?

Ensure that home infusion therapy has been arranged

An older adult client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a PICC line. Which of the following actions should the case manager perform prior to discharge?

Ensure that home infusion therapy has been arranged.

A facility has identified an increase in health care-associated urinary tract infections (UTIs) on the medical-surgical unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process?

Establish best practice guidelines for reducing the incidence of UTIs.

A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following client injuries receives treatment first? A. Hemothorax B. Open humeral fracture C. Multiple deep abrasions on the arms and face D. Superficial partial-thickness burns on both legs

Hemothorax The nurse should apply the survival potential priority-setting framework in mass casualty situations, when resources are scarce and resources must be allocated to save the greatest number of lives. While it could seem that the client who is most at risk should receive priority care, this client is the lowest priority. The nurse should assign the highest priority to the client with injuries that are severe who has the potential to survive with treatment. Therefore, the nurse should recommend that the client who has a hemothorax receives treatment first. A hemothorax is life-threatening, but with chest-tube insertion and stabilization, the client is likely to survive. Incorrect Answers: B. A client who has an open fracture does not have an immediate threat to life and can wait for treatment; therefore, the nurse should recommend that another client receive treatment first. C. A client who has multiple deep abrasions does not have an immediate threat to life and can wait for treatment; therefore, the nurse should recommend that another client receive treatment first. D. A client who has relatively minor burns does not have an immediate threat to life and can wait for treatment; therefore, the nurse should recommend that another client receive treatment first. /

A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2 hr. The client tells the nurse that she has called a taxicab and is leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next?

Inform the client about the risks she may encounter by leaving the facility

A nurse manager is coordinating staff assignments for RNs and licensed practical nurses (LPNs) following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care?

LPNs provide care to class III (green tag) clients. LPNs can provide care for class III clients, who have nonurgent, minor injuries. Class IV clients are expected to die or have died. This would be an appropriate assignment for assistive personnel, not an RN. Class I clients require immediate attention typically due to airway obstruction or shock. This would not be an appropriate assignment for the LPNs due to the need for an initial nursing assessment. Class II clients require treatment within 30 min to 2 hrs. This would not be an appropriate assignment for the LPNs due to the need for an initial nursing assessment.

A staff nurse detects alcohol on the breath of another nurse working on the unit. He observes that her gait seems unsteady, and she occasionally slurs her speech. Which of the following actions should the nurse take if he suspects that his colleague is under the influence of alcohol?

Notify the charge nurse of his assessment.

A staff nurse at a long-term care facility is evaluating an assistive personnel (AP) caring for a group of clients who require restraints. Which of the following is an appropriate action by the AP?

Placing the restraint tie on a moveable part of the bed frame not the side rails, to prevent constriction when changing the position of the bed. The nurse should secure mitten restraints at the client's wrist

A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following should the charge nurse do? (Select all that apply.)

Role model a positive approach to the changes is correct. It is important for the charge nurse to role model positive behaviors and demonstrate support of the change. Encourage staff members who support the changes to discuss the issue with resistant staff is correct. Redirect the conversation when negative comments about the changes are made is incorrect. The charge nurse should give staff members who oppose the change the opportunity to verbalize their objections and thereby discuss possible solutions. Peers can serve as change agents and encourage others to embrace the changes. Suggest that resistant staff members transfer to a different unit is incorrect. This approach avoids conflict rather than attempting to resolve it. Reprimand staff members who are resistant to the changes is incorrect. Resistance to change is a normal part of the change process. The charge nurse should use positive strategies to aid in acceptance of the proposed change.

A nurse is reviewing facility data on hand hygiene adherence and finds that nurses are not performing hand hygiene after client contact 28% of the time. Which of the following is the first action the nurse should take when developing a plan to increase employee hand hygiene adherence?

Set a goal for improvement in adherence

A nurse is caring for a client who is 3 days postoperative following open heart surgery and is to transfer to the medical-surgical unit. Which of the following should the nurse plan to include in the verbal report?

The client's level of consciousness

A nurse manager is reviewing the stages of conflict resolution with the nursing staff. The nurse manager should instruct the staff to expect the stages of the conflict to occur in what order? (Order the steps of the process by placing the letters in the correct sequence.)

The first stage of the conflict process is latent conflict, which involves awareness of potential situations that can create conflict. Stage two is perceived conflict, where those affected are discussing the situation, but in an impersonal manner. Stage three is felt conflict, where those affected become personally involved. Stage four is manifest conflict, where those involved begin to take action. Stage five is conflict aftermath, where those involved recognize the positive and negative outcomes in how the situation was managed.

A charge nurse is evaluating a newly licensed nurse at the end of orientation. Which of the following behaviors indicates the nurse is using effective time management skills?

The nurse will develop a list of non-essential tasks that can wait until more urgent tasks are complete and demonstrate effective time management.

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.)

The right to be treated with respect and dignity is correct. The code of ethics for nursing requires nurses to treat clients with respect and dignity. The right to refuse their medications is correct. Clients have the right to refuse treatment. The right to leave regardless of provider recommendations is correct. Clients have the right to leave the facility against medical advice. The right to be fully informed of their health conditions is correct. It is the nurse's responsibility to fully inform clients of their health conditions. / The right to full access of the facility is incorrect. Clients only have the right to access common areas of the facility.

A case manager is initiating the plan of care for a client receiving warfarin who had a stroke. Which of the following is most important for the case manager to include in the client's plan of care?

scheduling follow-up tests for prothrombin time and INR