ATI Management Practice A

A nurse is delegating tasks to assistive personnel (AP). Which of the following statements by the nurse includes the five rights of delegation?

"Ambulate the client in room 316 to the end of the hall before lunch and report any shortness of breath." The nurse should identify that the five rights of delegation include right task, circumstances, person, direction, communication, and level of supervision. This statement contains all five rights of delegation and is an appropriate task for the nurse to delegate to an AP.

A charge nurse in a long-term care facility is reviewing message boards in various client rooms. Which of the following information should the charge nurse request one of the nurses remove from a client's board?

"Hospice nurse visit at 1600" The charge nurse should request removal of any information concerning the client's medical diagnosis and/or treatment from message boards. HIPAA specifically prohibits posting a client's private health information because this violates the client's right to confidentiality.

A nurse is reinforcing discharge teaching with a client who is 2 days postpartum. The client expresses concern about a lack of family support and limited financial resources. Which of the following responses should the nurse make?

"How do you feel about discussing your concerns with a social worker?" This is a therapeutic response by the nurse because it addresses the client's concerns and ultimately provides the client with resources to help meet her specific needs. The social worker can connect the client with supportive community resources.

A nurse is reinforcing teaching about home safety with an older adult client. Which of the following statements by the client indicates an understanding of the teaching?

"I will paint the edge of each of my entry steps a different color." This statement by the client indicates an understanding of the teaching. Painting the edge of each entry step a different color provides contrast, making it easier for the client to see.

A nurse is assisting with the care of a client who has terminal cancer and is receiving chemotherapy. The client tells the nurse that she is only continuing treatment for her family's sake. Which of the following responses should the nurse make?

"Let's talk about your reasons for continuing treatment." This response by the nurse is therapeutic because it focuses the conversation on the key components of the message and allows the client to discuss the treatment and any concerns she is having. The nurse also validates the client's feelings and thoughts, which enhances trust between the nurse and the client.

A nurse is reinforcing teaching with a newly licensed nurse about the role of the nurse in informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"My signature on the consent form indicates the client gave consent for the procedure voluntarily." The nurse's signature on the consent form confirms that the client is competent to give consent, the client gave the consent voluntarily, and that the client's signature is authentic.

A charge nurse is talking with two assistive personnel (AP) who are angry about the way lunch breaks are scheduled on the unit. Which of the following statements by the charge nurse demonstrates the use of compromise?

"You can take turns going to lunch first every other week." Successful negotiation through compromise requires that each party give up something. The charge nurse should suggest an alternating lunch schedule, in which each party gives up what they want only part of the time. This use of compromise results in a win-win outcome for all parties.

A nurse enters a client's room at the beginning of a shift. Which of the following findings requires intervention by the nurse?

A capped bottle of sterile water that was opened 36 hr ago. The nurse should discard a bottle of sterile water that was opened more than 24 hr ago.

A nurse is discussing the condition of several clients with an assistive personnel (AP) prior to routine vital sign measurement. The nurse should plan to measure vital signs for which of the following clients rather than delegating this task to the AP?

A client who has new onset atrial fibrillation and reports lightheadedness. Clients who have new onset atrial fibrillation often experience lightheadedness, tachycardia, and hypotension. Because the client's condition is unstable and might require nursing judgment, the nurse should plan to measure the client's vital signs since these tasks are outside the AP's range of function.

A nurse is assisting with the evacuation of clients who have been triaged following a mass casualty event. Which of the following clients should the nurse recommend for first transport to the health care facility?

A client who has paradoxical respirations and has been assigned a red tag. When using the airway, breathing, circulation approach to client care, the nurse should transport the client who has paradoxical respirations first. A client who has paradoxical respirations requires immediate intervention for survival, due to airway compromise.

A nurse is preparing to document client care in the electronic health record for a client who is postoperative. Which of the following should the nurse include in the documentation?

A treatment that was refused by the client The nurse should document treatments that were omitted due to client refusal in the medical record.

A charge nurse is evaluating the documentation of care for four clients by a newly licensed nurse. Which of the following entries requires intervention by the charge nurse?

Administered 10.0 u of insulin SQ to client for elevated glucose level. This entry requires intervention by the charge nurse for the use of unapproved abbreviations (u, SQ), a trailing zero (10.0), and incomplete information including type of insulin, how it was administered, and glucose level.

A nurse on a pediatric unit is assisting with the care of a group of clients. Which of the following clients would benefit most from an interprofessional care conference?

An infant who has cystic fibrosis and is continuing to lose weight. When using Maslow's hierarchy of needs, the nurse should determine that this client is the priority for an interprofessional care conference to meet the client's need for food and fluids. This client is at risk for inadequate nutrition resulting in impaired growth. Addressing this problem requires a multidisciplinary approach, including a dietitian.

A nurse is contributing to the plan of care for a client who is newly admitted to a rehabilitation facility. Which of the following actions should the nurse take first?

Ask the client to identify his goals for recovery. The first action the nurse should take using the nursing process is to collect data from the client. By asking the client to identify his goals for recovery, the nurse helps ensure the plan of care reflects issues that are important to both the client and health care team.

A nurse is contributing to the plan of care for a client who has a prescription for a 24 hr urine specimen. Which of the following interventions should the nurse plan to include? (Select all that apply.)

Begin the timed collection by discarding the first specimen. The nurse should begin the timed collection when the client voids. This nurse should discard the first specimen. Post the times for urine collection above the toilet in the client's bathroom. The nurse should post information about the urine collection testing, including the start and end time, in a prominent place to prevent accidental discarding of urine. Obtain a clean specimen collection container for use during the test. The nurse should obtain a clean container for the client to use during the testing period to avoid contamination of the specimen.

A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. Which of the following actions should the nurse take first?

Check the client for injuries. When using the nursing process, the nurse should identify that the priority action is to collect data from the client. Therefore, the first action the nurse should take is to check the client for injury.

A nurse is assisting with a presentation about nutrition for cancer prevention at a community center. Which of the following information should the nurse suggest including?

Consume fatty fish twice a week. Consuming fatty fish at least twice weekly helps to increases omega-3 intake as part of cancer prevention. Eating white meats such as chicken or fish is preferred to consuming red meats.

A charge nurse is a member of the resource management team for a skilled care facility. Which of the following actions should the charge nurse implement to ensure the facility is providing cost-effective wound care for clients?

Develop a spreadsheet to prepare a budget for wound care supplies. The nurse should use a spreadsheet to manage numerical data for the preparation of a budget. The use of a spreadsheet allows the nurse to analyze this data to ensure that cost-effective care is provided to clients.

A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling. Which of the following actions should the charge nurse take?

Encourage each staff nurse to give up something as part of the negotiation. The charge nurse should encourage each staff nurse to give up something as part of the negotiation so that a compromise can be reached that is a win-win situation for each party.

A nurse enters the room of a client who is sleeping and observes sparks coming from a frayed bed plug in the client's electrical outlet. Which of the following actions should the nurse take first?

Evacuate the client. The greatest risk during a fire or a threat of fire is injury to the client or others; therefore, the first action is to evacuate the client from the room. This action is the first step of the Rescue, Alarm, Confine, and Extinguish (RACE) protocol.

A nurse is assisting with the care of a client who was admitted with deep-vein thrombosis. The client has decided to leave against medical advice. Which of the following actions should the nurse take?

Explain to the client the risk involved in leaving the hospital. The nurse has a legal responsibility to inform the client of the potential risks involved with leaving against medical advice.

A nurse is reinforcing teaching with a newly licensed nurse about the administration of opioid pain medication. Which of the following instructions should the nurse include?

Have a second nurse witness disposal of the unused portion of the client's medication. The nurse should ask a second nurse to witness the disposal of any unused portion of the client's medication. The witnessing nurse should also sign the medication record as a witness to the disposal of the unused medication.

A home health nurse is reinforcing teaching about the effects of carbon monoxide poisoning. Which of the following manifestations should the nurse include?

Headaches The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control, and muscle weakness are manifestations of carbon monoxide poisoning.

A nurse is assisting with the discharge planning for a client. Which of the following actions should the nurse plan to take?

Include community resource phone numbers with the client's discharge instructions. The nurse should provide the client with contact information for community resources, as well as the provider, to enhance care and provide easy access in the event of complications or questions.

A nurse is monitoring an assistive personnel (AP) who is calculating I&O for a postoperative client. The client has a Jackson-Pratt drain and an indwelling urinary catheter. The nurse should recognize that the client's output is calculated and recorded correctly when the AP performs which of the following actions?

Includes emesis and wound drainage in the total recorded output. The nurse should recognize that the AP understands the concept of calculating a client's intake and output when the AP includes emesis and wound drainage into the calculation of the client's total output.

A nurse overhears two assistive personnel (AP) discussing the details of a client's diagnosis and treatment plan in the hospital cafeteria. Which of the following actions should the nurse take?

Inform the APs that the conversation violates the client's confidentiality. The nurse should intervene immediately to stop the conversation and protect the client by informing the APs that the conversation violates the client's confidentiality.

A nurse is caring for an adolescent client who requires a blood transfusion. The client's parents will not consent to the transfusion due to religious beliefs. Which of the following actions should the nurse take?

Inform the charge nurse and recommend that social services be contacted. The nurse has an obligation to act as an advocate for the client. The nurse should inform the charge nurse of the parents' decision and recommend that social services is contacted to further advocate for the client.

A nurse observes an assistive personnel (AP) taking a picture of a client who has not given consent. The nurse should identify the AP has committed which of the following torts?

Invasion of privacy. Invasion of privacy is a violation of the client's right to privacy, such as using the client's name for profit or taking pictures of the client without consent.

A nurse has just received a change-of-shift report for a group of clients. Which of the following actions by the nurse demonstrates effective time management skills?

Keeps a client to-do list for the day. The nurse should keep a client to-do list for the day, which allows the nurse to track the completion of the tasks as well as organize and manage time wisely.

A nurse is discussing delivery models of care with a group of newly licensed nurses. Which of the following should the nurse include as an example of the functional nursing model of care?

Nurses are assigned specific tasks to perform for each of the clients. Nurses use a functional nursing model when assigning specific tasks to staff. This approach places the focus on the task to be performed.

A nurse is assigned to care for a client who is in isolation. Which of the following actions should the nurse take to manage time effectively while caring for this client?

Organize care into groups that can be performed at one time. The nurse should implement this strategy to streamline the workflow by providing less fragmented care and reducing time spent traveling from area to area.

A nurse is contributing to the development of a fall prevention policy for clients who have dementia. Which of the following sources of information should the nurse identify as the primary guideline for the creation of the policy?

Peer-reviewed nursing journals The nurse should collect data from peer-reviewed journals when contributing to the development of a new policy. This is the primary guideline the nurse should use because it is current, accurate, and research-based.

A nurse is monitoring a client who is receiving IV fluids via an infusion pump and notes the pump is malfunctioning. Which of the following actions should the nurse take?

Place a tag on the IV pump. The nurse should place a tag on the malfunctioning IV pump and remove it from service to prevent injury to the client and others.

A nurse is preparing to delegate assignments after receiving change-of-shift report. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Provide postmortem care. The nurse should assign the AP to provide postmortem care because this task is within the AP's range of function.

A nurse is contributing to the plan of care for a client who has acute hypothyroidism. Which of the following interventions should the nurse include in the plan?

Provide the client with a reduced-calorie diet. The nurse should provide the client who has hypothyroidism with a reduced-calorie diet. Hypothyroidism causes the client's metabolism to decrease, which can result in weight gain. A reduced-calorie diet will help the client keep weight gain to a minimum and contribute to weight loss.

A nurse is contributing to the plan of care for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following members of the interprofessional health care team should the nurse consult to assist the client with glucose management?

Registered dietitian The nurse should arrange a consult with a registered dietitian to help the client with meal and snack plans, which will ensure stable blood glucose levels.

A nurse is assisting in the planning of in-home care for a client following a right hip arthroplasty. Which of the following interventions is the nurse's priority?

Reinforce teaching about the client's use of a walker. The greatest risk to this client is injury from a fall. Therefore, the priority intervention is to reinforce teaching with the client about safe ambulation with a walker.

A nurse on a facility's performance improvement team is assisting to develop practice guidelines for performing bladder scans. Which of the following actions should the nurse take prior to developing a policy and procedure for this task?

Review evidence-based practice data related to bladder scanner use. To facilitate the best client outcomes, the performance improvement team should review available evidence-based practice data related to this task. This should provide the most accurate and comprehensive information on which to base policy and procedure decisions.

A nurse is preparing to reinforce discharge teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take? (Select all that apply.)

Select an interpreter who is the same gender as the client. The nurse should select an interpreter who is the same gender as the client to avoid embarrassment. Ensure interpreters provided by the facility have knowledge of medical terminology. To accurately relay medical information, interpreters should have specialized medical training. Choose an interpreter from the same ethnic background as the client. The nurse should select an interpreter that is from the same ethnic background as the client to prevent possible conflicts and differences in dialect.

A nurse in a long-term care facility is caring for a client who had a stroke 1 week ago. The client is experiencing left-sided weakness, difficulty swallowing, drooping of the mouth, inarticulate speech, and memory loss. Which of the following referrals is the priority for the nurse to make?

Speech therapy When using the airway, breathing, circulation approach to client care, the priority referral is to the speech therapist. Difficulty swallowing indicates that this client is at risk for aspiration; therefore, a referral for speech therapy is the priority.

A charge nurse in a long-term care facility is monitoring the activities of an assistive personnel (AP). Which of the following actions by the AP indicates that the charge nurse should intervene?

Stands with feet close together while transferring a client from the bed to a chair. The AP should stand with feet wide apart while transferring a client from the bed to a chair to increase stability and prevent self-injury.

A nurse arrives for her shift and is assigned more clients that she feels is safe. The charge nurse states there are no other options due to a shortage in nursing staff. Which of the following actions should the nurse take?

Submit a written complaint to the nursing supervisor. The nurse should submit a written complaint to the nursing supervisor detailing her concern if she must accept an assignment for more clients than she feels is safe. This written complaint ensures that the facility is aware of the issue and indicates that the nurse made an attempt to address the situation.

A nurse is caring for a client who received a skin tear during a routine dressing change. After completing an incident report, which of the following actions should the nurse take?

Submit the incident report to the nurse manager for review. The nurse should complete an incident report for unusual occurrences or variances in client care. The nurse manager should have the opportunity to review the information in order to begin the quality review process.

A nurse is assisting with the discharge of a client who has a new permanent colostomy. The client expresses concern about learning to care for the appliance and obtaining supplies discretely. Which of the following actions should the nurse take? (Select all that apply.)

Suggest that the client join an ostomy support group. An ostomy support group, such as those affiliated with the United Ostomy Association, can provide helpful information for clients who have a new ostomy. Arrange a follow-up appointment with an enterostomal therapy nurse. An enterostomal therapy nurse will follow up with the client regarding ostomy care. Provide the client with the name and number of an ostomy supply delivery service. The nurse should provide the client with initial ostomy supplies and inform the client of medical supply companies from which he can obtain future supplies or have them delivered discretely. Request a social work referral for the client to discuss financial concerns. The nurse should request a referral to a social worker. A social worker can assist the client with identifying community resources and providing financial counseling.

A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility?

The client develops command hallucinations. Command hallucinations involve hearing "voices" that direct the client to take specific actions. These actions can be directed at causing self-harm or injury to others. To provide for safety of the client and others, the nurse should recommend that the client be transferred to an acute care facility.

A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events should the nurse document as a variance?

The client has a circular area of nonblanchable redness on her left heel. A variance occurs when expected outcomes of the critical pathway are not met. The nurse should document that the client has a circular area of nonblanchable redness on her left heel as a variance because this indicates the initial stage of a pressure ulcer and is not an expected outcome.

A nurse is participating in the unit's performance improvement program. The nurse should recognize that which of the following is a quality indicator?

The facility-wide fall injury rate for the previous quarter is 3%. This is a valid outcome indicator because it provides statistical evidence related to quality of care.

A nurse in a skilled nursing facility is caring for a group of clients. Which of the following actions demonstrates the nurse's role as client advocate?

The nurse assists a client in communicating end-of-life decisions to the provider. The nurse acts in the role of client advocate when protecting the client's legal and ethical rights.

A community health nurse is reinforcing teach with a group of parents about home safety for children of various age groups. Which of the following information should the nurse plan to include?

The supine position is the safety for sleeping infants. The nurse should reinforce placing an infant in the supine position is recommended by the American Academy of Pediatrics to decrease the risk of sudden infant death syndrome (SIDS).

A nurse is participating on a committee that is revising the facility's policies and procedures for infection control. Which of the following statements should the nurse recommend to include in the facility's infection control manual?

Use a 1:10 bleach solution to clean blood spills. The nurse should recommend using a 1:10 bleach solution to decontaminate blood spills.