EDAPT: NCLEX Readiness: Management of Care

The nurse is in charge of a surgical unit with two licensed vocational nurses (LVNs). For each task, click to select if it is appropriate or not appropriate for the nurse to delegate it to the LVN to perform unsupervised.

*Appropriate:* Routine dressing of a four-day post-operative knee replacement wound Assisting a client with a post-below-the-knee amputation to the bathroom for a bath Accompanying a client for an x-ray after an orthopedic cast was applied Caring for a 24-year-old with diabetes mellitus Caring for an 8-year-old with Hirschsprung's disease *Not Appropriate​:* Dressing of a suspected infected abdominal wound Caring for a 16-year-old admitted in sickle cell crisis Caring for a 5-year-old one day post tonsillectomy Caring for a 2-year-old with epiglottitis in a mist tent

Click to specify if each action is appropriate or not appropriate when documenting a client's health or medical record.

*Appropriate:* Use time and date; be specific, accurate, and complete. Use black ink when using handwritten charts. Follow rules of grammar and punctuation. Chart your own care, observations, and teaching. Chart as soon and as often as necessary​. Correct errors promptly. *Not Appropriate:* Erase, use correction fluid, or scratch out errors. Chart once at the end of the shift. Use blue ink when using handwritten charts. Pre-chart to save time.

A nurse is caring for a critical client. As the critical client's condition worsens, the nurse needs to delegate care of other clients to unlicensed assistive personnel (UAP). Click to specify if each task is appropriate or not appropriate for the nurse to delegate to the UAP. ​

*Appropriate:* Weighing a client Performing perineum care Assisting a client to the restroom Reinforcing safe transfer from bed to chair Ambulating the client in the hallway using crutches ​Documenting input and output for a client with chronic neurogenic bladder *Not Appropriate:* Reconnecting intravenous (IV) fluids Suctioning an endotracheal tube Evaluating the client's pain Performing a sterile dressing change

For each client assessment finding, click to specify if the finding is consistent with a burn injury or suspicious injury. Each finding may support more than one injury. Each column must have at least one response option selected.​

*Burn Injury:* Blisters Continuous sobbing Glove-like redness on left hand *Suspicious Injury:* Sharply-demarcated lesions with eschar Bruises in different stages of healing Glove-like redness on left hand

Nurses must identify professional values and ethical issues affecting client care and practice in a manner consistent with the code of ethics for nurses. Match each nursing action to the professional value or ethical principle it represents.

*Confidentiality* - The nurse observes an open chart on the desk in the hallway and closes it to avoid improper access.​ *Beneficence* - A client requests pain medication following an appendectomy. The nurse agrees to return in 30 minutes to administer the next dose. *Justice* - A nurse observes a provider making rounds to clients on the unit and preparing to leave the unit without seeing the nurse's client. The nurse requests the provider see their client. *Advocacy* - A client is prescribed the wrong medication. The nurse identifies the error and seeks clarity from the provider about the error.

Identify the correct and incorrect nursing actions that should be taken. Select one option in each row.

*Correct:* Report the violation to the supervisor. Explain the importance of privacy to the UAP. Recognize this as an EMTALA violation. *Incorrect:* Complete a focused psychosocial assessment on Strykner. Remove the UAP from the client assignment.

Click to specify if the nursing actions could result in a legal malpractice claim.

*Could Result in a Malpractice Claim:* Incorrectly recording the time of an event Documenting for the charge nurse Charting events in advance *Will Not Result in a Malpractice Claim:* Identifying a late entry per facility policy Documenting concisely

Click to specify if the nursing action demonstrates or does not demonstrate client advocacy.​

*Demonstrates Advocacy​:* Explaining a diagnosis​ Providing support when a client makes medical decisions​ Coordinating medical care, such as medical appointments, hospitalizations, and surgeries​ Assisting clients in obtaining medical equipment​ Providing clients with health and wellness advice and coaching​ Remaining in a client's room while the healthcare provider explains treatment options​ *Does Not Demonstrate Advocacy​:* Communicating the nurse's preferences regarding healthcare decisions​ to the family

Identify if each nursing action demonstrates ethical practice or does not demonstrate ethical practice.

*Demonstrates Ethical Practice:* Notifies a healthcare provider about a client who declines dialysis and wants to stop treatment Educates a client about the use and benefits of incentive spirometry when they refuse to use it *Does Not Demonstrate Ethical Practice:* Refuses to stay overnight on a mandated shift due to fatigue and leaves at the end of the current shift Confronts and does not report a coworker who took narcotics out of a medication dispensing cabinet for personal use Asks a client, "Will you take a walk around the unit with me so your roommate can speak to their healthcare provider about their cancer results?"

Match each clinical example to the aligning quality concept.​​

*Efficient* - A nurse only takes necessary supplies from the supply cabinet to initiate the intravenous line.​​ *Safe* - A healthcare provider checks all prescribed medications for interactions with a newly prescribed medication. *Client-centered* - A client's treatment plan includes telehealth psychiatric visits because the client does not have easy access to transportation. *Equitable* - Two clients receive the same treatment options for the same illness. *Effective* - A healthcare provider prescribes newly approved medication to treat hyperlipidemia to a client with high low-density lipoprotein levels. *Timely* - A client who is having an ischemic attack is evaluated and treated in the emergency department immediately upon arrival.

Click to specify which factors increase or decrease quality clinical decisions.​

*Increases Quality Decision Making​:* Following up on cues within the assessment data​ Use of open-ended questions​ The nurse's knowledge of health and illness​ Ability of the nurse to organize data​ The client's ability to clearly communicate their needs​ The nurse's understanding of the client's current situation​ *Decreases Quality Decision Making​:* The client's desire to keep their health history private​ ​The nurse's ability to quickly complete the admission assessment​

Coordinated care in relation to admission, transfer, and discharge is one of the key areas of the registered nurse's scope of practice. Click to specify if the activities that are indicated or contraindicated within the scope of practice.

*Indicated:* Collaborate with an interdisciplinary team​​. Inform the client of their individual right to confidentiality. Intervene if client rights are violated​​. Encourage co-workers to avoid discussing clients at the nurse's station. ​​ *Contraindicated​:* ​Obtain a client's informed consent for a procedure. ​ Encourage clients not to refuse a procedure when it is in their best interest.

When planning care for this child, click to specify if each nursing intervention is indicated, nonessential, or contraindicated for the care of this client.

*Indicated:* Contact the child's parent/legal guardian. Collaborate with the nursing supervisor. Prepare to notify the proper authorities as required by facility policy. *Nonessential:* Give the child a toy to play with as a distraction. *Contraindicated:* Ask the caregiver to describe events leading up to the injury at the bedside. Remove the child from the family's custody.

Select the positive communication behavior for each action.

*Value Team Input:* Document client data accurately and in a timely manner. Seek clarification when the treatment plan is unclear. Focus on the client's needs and outcomes during all communication. *Exchange Relevant Information With the Team:* Use the ISBAR (information, situation, background, assessment, and request) format for critical conversations. Focus on the client and their care when conflict arises. Repeat what is heard so the person who shared the information can confirm the information is understood. *Coordinate Workload with Colleagues:* Delegate care appropriately. Care for a colleague's assignment if one of their assigned clients needs their attention. Assess the capabilities of individuals within the team.

A nurse posts a selfie on a social media site. A client's first initial, last name, room number, and attending provider's name can be seen on the whiteboard (e.g., communication board) in the background. The nurse is disciplined by the hospital for which violation? ​Click to specify if the action by the nurse violates or does not violate each of the following.

*Violates:* Health Insurance Portability and Accountability Act Client's privacy and confidentiality *Does Not Violate:* Hospital's privacy and confidentiality Hospital's property

Click to select each description for the component of the scope of practice.

*Who:* A registered nurse must be formally educated and maintain an active license to practice nursing. *What:* Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations. *Why:* As society changes, nurses must adapt to maintain their obligation to positive client outcomes. *When:* Nurses provide care anytime there is a need for knowledge, caring, or leadership. *Where:* Nursing occurs in many settings and environments. *How:* Nurses are expected to perform in a specific manner displaying professional behaviors.

A nurse is managing four assigned clients on the evening shift. Place the clients in the order in which the nurse should see them, from first to last.

1. Client with sepsis who is developing petechiae 2. Client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site 3. Client 4 hours post tracheostomy who has a moderate amount of serosanguinous drainage on the tracheotomy dressing 4. Client with a history of carpal tunnel syndrome with hand numbness

The quality improvement (QI) committee at a large, urban hospital organization is reviewing 30-day readmission rates. The QI committee recognizes that there is a need for more client discharge education. The topic of discharge education is referred to the research department to investigate the issue and find an evidence-based solution. ​ Before starting, the committee needs to review the steps in the research process. Place the research steps in the correct order.

1. Define and describe the problem​ 2. Develop a plan to gather information to address the problem​ 3. Implement the study​ 4. Analyze and interpret the results​ 5. Disseminate the findings​

A pediatric primary care office initiated a quality improvement process to increase the vaccination rate of children. Place the quality control steps in the order they should be performed, from first to last.

1. Identify the American Academy of Pediatrics recommendation that all clients should receive preventative vaccines. 2. Collect electronic medical record documentation regarding vaccination rates, recommendations, and education provided to clients.​ 3. Evaluate data collected. ​ 4. Provide education to healthcare providers and nurses regarding preventative vaccine screenings and recommendations.​

The nurse is considering which actions to take next. Which actions should the nurse implement? Select all that apply.

Collaborate with the nursing supervisor regarding the process for mandatory reporting of suspected child abuse. Discuss the physical assessment findings with the provider. Record the statements of the caregiver into the medical record using direct quotes whenever possible. Document objective findings of the physical assessment into the medical record.

The data was collected and analyzed. A summary report was presented to the stakeholders. What is the committee's next step?​

Create a pilot study of a discharge protocol.

Match each term with the correct explanation.

*Advance directive* - Legal instructions that outline a client's healthcare wishes and address future medical care but can also include medical events (e.g., dementia, stroke, or coma)​ *Power of attorney​* - A legal document authorizing a designated person to make decisions for another person​ *Healthcare proxy​* - A person designated by the client to make medical decisions on their behalf​ *Living will​* - A written legal document outlining medical treatments and preferences a client wants should the client become terminally ill and unable to make these decisions on their own *Do Not Resuscitate* - A medical order to not perform cardiopulmonary resuscitation (CPR) on a client in respiratory or cardiac arrest​

A registered nurse (RN) on a busy medical-surgical unit needs to delegate tasks to a licensed practical/vocational nurse (LPN/LVN) and/or unlicensed assistive personnel (UAP). For each RN action, click to specify if the action demonstrates appropriate delegation or inappropriate delegation.

*Appropriate Delegation:* Requesting the UAP to pick up prescribed blood from the hospital blood bank Having the UAP transport a stable client via wheelchair to imaging​ Requesting the LPN perform a routine sterile dressing change *Inappropriate Delegation:* Requesting the LVN to conduct an admission assessment on a client transferred from the emergency department Having the UAP collect vital signs on a client newly arrived on the unit Requesting the UAP to assign lunch times to other UAPs on the unit

Click to specify if the information is appropriate or not appropriate to include in documentation.

*Appropriate:* 10 mL of hydromorphone infused and 110 mL of remaining fluid present within the PCA Client reported, "The medicine is helping my pain go away." Vital signs stable, pain rated 5 out of 10 on the FACES scale, vascular access site clean, dry, and intact *Not Appropriate:* Client is currently watching TV quietly, appears relaxed and pain-free

A nurse is assisting with the discharge planning for a client. Click to specify if each nursing action is appropriate or not appropriate for discharge.

*Appropriate:* Determine the client's need for home medical equipment​. Obtain printed instructions for medication self-administration​. Provide the family with a list of community resources that can provide assistance.​ Discuss the importance of attending follow-up appointments​. *Not Appropriate​:* Provide a list of all medications the client received in the facility​. Arrange a payment plan between the client and their insurance company.​

A nurse in a provider's office is reinforcing teaching to a client. The client states, "I want to have an advance directive." Click to specify if each nursing action is appropriate or not appropriate.

*Appropriate:* Provide written information about advance directives​. Ensure that the advance directive reflects the client's current decisions​. Inform all healthcare team members of the client's advance directives​. *Not Appropriate:* Tell the client that the spouse must be the healthcare proxy​. Obtain provider permission for the advance directives​. Request a "Do Not Resuscitate" prescription from the provider​.

A nurse requires the assistance of an interpreter to reinforce education with a client prior to discharge. Drag the actions the nurse should take to the boxes on the right.

Determine client understanding frequently. Use non-medical terms to communicate. Prepare the interpreter for the information to be discussed. Allow time for the interpreter to be introduced to the client.

Before obtaining informed consent, the nurse should address the client's __________.

Understanding of the procedure

The nurse cares for a client with a terminal disease who has an advance directive and healthcare provider prescription supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time?

Explain the client's wishes to the client's child​.

When caring for a client with ulcerative colitis, which nursing activities are appropriate for the registered nurse (RN) to delegate to the licensed practical nurse (LPN)? Select all that apply.

Monitor for a change in bowel sounds Remind the client to track daily weights Administer a prescribed suppository

The nurse recognizes that a priority concern for Packer is __________ and that the client should have __________. The nurse will ask the healthcare provider to consider __________.

Shock A type and crossmatch Blood products

The client's partner arrives at the emergency department and presents the client's durable power of attorney. How should the nurse interpret this document?

The client has indicated who should make decisions for their care if unconscious.

A nurse receives a change-of-shift morning report for four clients. Which client should the nurse assess first?

Client who is 48 hours post abdominal hysterectomy; client is ambulatory and reports aching pain in the left leg

A 15-year-old with abdominal pain is admitted to the pediatric unit. After the caregivers leave the unit to get some food, the client tells the nurse that they might have contracted human immunodeficiency virus (HIV). They want to get tested, but they do not want their caregivers to know about the test. Which is the best response by the nurse?

"I'll call the provider for the order. No one will tell your parents."

A nurse manager overhears nurses talking about social media and healthcare at the nurse's station. Which statement by a nurse is correct?

"Nurses should not share any client identifying information to protect the client's right to privacy and confidentiality."

The nurse is caring for a pediatric client with Kawasaki disease. Prior to the nurse administering intravenous (IV) antibiotics, the client's parent states, "We don't believe in antibiotics. Healing comes from within, and medications are toxic to that process." What is the nurse's best response?

"Please tell me your understanding of your child's condition."

Which statement made by the nurse indicates an understanding of clinical pathways?​

"The pathway shows an estimate of the number of days a client will be hospitalized."​

The nurse managers at a healthcare facility identify that clients remain in the post-anesthesia care unit (PACU) after discharge criteria are met. The manager asks the Performance Improvement Council to address the issue. What questions should the council ask at the onset of the quality improvement project? Select all that apply.​

"What is the impact of the delays on the operating room schedules?" "How long are clients remaining in PACU after meeting discharge criteria?" "Are delays more common before discharge home or admission to the floor?"

A charge nurse needs to make room assignments for the following clients. Match each client with the appropriate room pairing.

*A client who is postoperative total hip replacement* - A client with a long leg cast following open reduction of a fractured tibia *A client who is undergoing 24-hour video-electroencephalogram (EEG)* - A client with pain related to alcohol-associated pancreatitis *A client with diphtheria* - A client with pneumonia

A nurse is triaging telephone messages. Which client should the nurse call back first?

Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 °F (38 °C)

A new graduate nurse is assigned a preceptor for orientation as a new nurse. The new graduate is nervous for the first day and is concerned about looking unprepared. The new graduate arrives on the unit before reporting and overhears the assigned preceptor complaining about having to train this nurse. Another nurse at the nurse's station overhears and agrees that too many new people are coming to the unit, and all the "difficult" clients are assigned to experienced nurses. The preceptor voices an additional concern that the new graduates "aren't prepared to really work" either. Click to select whether the nursing actions are indicated or not indicated for the new graduate nurse to take to manage the conflict.

*Indicated:* Share the desire to learn from the preceptor's expertise which will involve asking questions. Ask the preceptor for a time during the shift to have a short discussion in the break room. *Not Indicated:* Leave the unit to find the nurse manager to talk about what was overheard. Focus on observation of the preceptor's nursing practice rather than taking on nursing actions. Work the shift with the preceptor and ask the preceptor to stay after the shift to talk about what was overheard. Ask another nurse who is more receptive to new graduates to be the preceptor. Offer to take the most difficult clients as soon as the precepting is completed.

Identify if the statements are intrapersonal, interpersonal, or intergroup conflicts.

*Intrapersonal:* A nurse feels overwhelmed with client care activities and prioritizes work tasks over meals and bathroom breaks. A nurse calls out sick to work because their child is sick while feeling an obligation to not leave the unit short-staffed. *Interpersonal:* A client's family does not agree with the client's Do Not Resuscitate order. The nurse disagrees with the nursing supervisor on safe staffing ratios. *Intergroup:* The nursing staff and hospital administration disagree with merit raises.

Identify the resources to be allocated for each client. Select one or more options in each row.

*Leukin:* IV start kit Oxygen Respiratory therapy Telemetry monitor *Strykner:* IV start kit Respiratory therapy Telemetry monitor Electrocardiogram *Incoming Ambulance Client:* IV start kit Oxygen Respiratory therapy Telemetry monitor Dressing supplies Electrocardiogram

A nurse is preparing to transfer a client who is 72 hours postoperative to a skilled nursing facility. Click to specify which information is needed or not needed when giving report.​

*Needed:* Status of advance directives​ Medical diagnosis​ Need for specific equipment​ *Not Needed​:* Type of anesthesia used​ Vital signs on the day of admission ​Client preferences for meals​

After explaining the risks and benefits of a planned surgical procedure, the healthcare provider asks the nurse to witness the client's signature on the consent form. With each situation, identify whether the nurse should or should not witness the client's signature based on the rules of informed consent.

*Nurse Should Witness​:* The client expresses a fear of postoperative pain. The client received a dose of hydrocodone for pain 12 hours ago. The client wishes to wait to sign the consent form until the spouse is present. *Nurse Should Not Witness:* The client asks whether a blood transfusion will be required during surgery.

Identify which actions or processes protect client privacy and confidentiality and which actions do not.

*Protects the Client:* Using two-factor authentication Changing passwords at set intervals Only allowing authorized individuals to have access to client information Adding a biometrics identifier Logging out of the computer each time documentation is complete *Does Not Protect the Client:* Allowing lifetime electronic health records use Logging into the computer at the beginning of each shift and reducing the browser when walking away from the desk

The design of this project is a mix of qualitative and quantitative data sources. Click to specify if the data sources are qualitative or quantitative.

*Qualitative:* Descriptions of other hospitals' client discharge education practices List of health conditions seen during readmission Opinions from staff regarding client discharge education *Quantitative:* Cost of discharge readmissions Number of clients who are readmitted

For each aspect of the "Right Supervision/Evaluation" step of delegation, click to specify if the aspect is the responsibility of the registered nurse, the unlicensed assistive personnel (UAP), or both. Each aspect may apply to more than one colleague.

*Registered Nurse:* Following up with a colleague Evaluating client outcomes Verifying if documentation was completed Retaining overall accountability for the client *Unlicensed Assistive Personnel:* Following up with a colleague Completing documentation Reporting how the client tolerated the activity/task ​ Retaining accountability for the task

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Click to specify whether the tasks are or are not the responsibility of state licensing boards.

*Responsibility:* Ensuring that healthcare providers comply with regulations *Not a Responsibility:* Monitoring evidence-based practice for clients with specific diagnoses Setting quality standards for accreditation of healthcare facilities Determining if medications are safe for administration to clients

For each instance of delegation, click to specify which of the five rights of delegation is being addressed. There may be multiple rights addressed for each example.

*Right Task​:* A nurse asks an unlicensed assistive personnel (UAP) to assist a client with eating. A registered nurse assigns a licensed vocational nurse (LVN) to care for the same clients as the day before. *Right Circumstance​:* An experienced nurse asks a new nurse to ambulate a client, so they can speak with a healthcare provider. *Right Communication:* A nurse asks a colleague to repeat what was delegated to be sure they understand. *Right Supervision:* A nurse checks that the delegate accurately documented the care provided. *Right Person:* A nurse asks an unlicensed assistive personnel (UAP) to assist a client with eating. An experienced nurse asks a new nurse to ambulate a client, so they can speak with a healthcare provider. A registered nurse assigns a licensed vocational nurse (LVN) to care for the same clients as the day before.

A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Arrange the nursing interventions in order of priority.

1. Position the client upright at a 45-degree angle 2. Administer oxygen via nasal cannula at 2 L/minute 3. Prepare suctioning equipment at the bedside 4. Call the healthcare provider 5. Administer furosemide 40 mg intravenously STAT 6. Insert an indwelling urinary catheter

A charge nurse on a pediatric unit is planning client care assignments for the oncoming shift. Which clients would be appropriate to assign to a licensed practical nurse (LPN) who was floated from an adult medical-surgical unit? Select all that apply.

14-year-old with diabetes mellitus 15-month-old with febrile seizures 2-year-old with gastroenteritis

A licensed practical nurse (LPN) is discussing some client findings with the registered nurse (RN). Which client would be the priority for the RN to assess?

70-year-old client with pneumonia who is receiving intravenous fluids and has a new S3 heart sound

A nurse is triaging pediatric clients in the emergency department (ED). Which client needs diagnostic imaging completed first?

A 16-year-old complaining of severe pain and swelling in the scrotum

A pediatric emergency department nurse receives reports on four clients. Which client should be seen first?

A child with bruising behind the ears after a football injury

The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments is appropriate for a shared room?

A client who had a bowel resection 1 day ago and a client with asthma exacerbation​

A client has just been told their medical condition cannot be treated successfully and they have approximately 6 months to live. Which referral is most appropriate by the nurse at this time?

A hospice agency

The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first?

Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 °F (38.3 °C)

Which statements related to ethical nursing practice are correct? Select all that apply.

Accountability is documenting that the nurse administered the wrong medication. Justice is providing the same level of care for a person who is homeless as an elected official. Nonmaleficence is reporting abuse of a client with dementia.

A client with sickle cell crisis reports severe generalized pain. What are the two priority nursing interventions in order?

Administering high-flow intravenous fluids Applying oxygen via nasal cannula

The nurse is presented with an ethical dilemma that involves a conflict between the client's rights of __________ and __________ versus the nurse's duty related to __________ and __________.​

Autonomy Confidentiality Beneficence Nonmaleficence

While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action?

Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen

The nurse prepares to transfer a client to diagnostic imaging. Drag and drop the information that must be reported to the boxes on the right.

Events leading to admission​ Current vital signs​​ Allergies​ Code status​ Condition status​

What should a medical record provide for all healthcare providers? Select all that apply.

Care given to the client Client's nursing problems Client's response to treatment Client's medical problems Care planned for the client

What are examples of improving resource utilization in nursing? Select all that apply.​

Charging supplies used to the client's medical record​ Providing appropriate discharge teaching to reduce readmissions​ Assigning vital signs to an unlicensed assistive personnel (UAP) instead of a nurse​ Tagging and reporting broken hospital equipment​

Highlight the findings that indicate the child's future risks for injury have been effectively and legally addressed by the nurse.​

Child Protective Services (CPS) was notified CPS accepted the nurse's report Nurse completed a written report Documented their objective findings in the Electronic Health Record (EHR)

When documenting an incident in the nurse's notes, what should the nurse include? Select all that apply.

Chronologic order of events of the incident Name of healthcare provider and family members notified Description of injury, including diagrams of injury placement Date, time, and location of incident

A nurse in the cardiac intensive care unit receives reports on four clients. Which client should the nurse assess first?

Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain

There has been a community disaster with multiple victims. Stable clients must be discharged to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply.

Client experiencing asthma exacerbation without respiratory distress and a peak flow at 85% of personal best​ Client with myasthenia gravis and ptosis in the evening​

The nurse is caring for a postoperative client who sustained an occupational injury at work and had surgery to repair a broken femur. The client is ready for discharge. Which nursing actions should be included as part of the referral process? Select all that apply.

Complete referral for durable medical equipment (e.g., wheelchair) Provide information about community services and resources Assess the need for a home health nurse/aide Assess the need for specialized therapists

Which of the following are required for effective communication for delegation? Select all that apply.

Complete: no question left unanswered Correct: information follows policy and procedure Concise: right amount of direction given Clear instruction: understood by the listener

Which are nursing practices that ensure client safety during transfer from one unit or facility to another? Select all that apply.

Coordinating care by reviewing the healthcare provider's prescriptions Using an ISBAR tool to give reports​ Maintaining continuity of care by providing a thorough report to the receiving unit or facility​

The next step of the plan is to gather information. Which data would the committee review related to current client discharge practices? Select all that apply.

Current discharge practices Client feedback Timeline for creating an evidence-based plan Staff feedback List of common health conditions seen for readmission

A deceased client with multiple gunshot wounds arrives by ambulance to the emergency department. The nurse is caring for the client's personal belongings, which may be needed as legal evidence. Which actions should the nurse take to properly secure and handle legal evidence? Select all that apply.

Do not allow family members, significant others, or friends to be alone with the client. Place paper bags on the hands and feet​. Cut clothing along the seams, avoiding bullet holes​. Collect all personal items, including items from clothing pockets​.

Care coordination can improve __________, __________, and __________ of the healthcare system.

Effectiveness Safety Efficiency

The client is recognized as a prominent community leader and visitors begin arriving to inquire about the client's condition. In planning care for this client, how will the nurse protect the client's confidentiality?​ Drag the actions that the nurse should take to the boxes on the right.​

Log off the computer when leaving the workstation​. Shred printed laboratory results before discarding. Ensure privacy when providing hand-off reports​. Do not answer questions from those not involved in client care​.

Which aspects of nursing care should not be delegated to an unlicensed assistive personnel (UAP)?​ Select all that apply.

Evaluating client outcomes​ Selecting the nursing diagnosis Assessing the client Reinforcing client education at discharge

Which is the best example of collaborative care?

Healthcare team members visit the client on walking rounds and discuss the plan of care.​

A client is brought to the emergency department (ED) dead on arrival (DOA) from a gunshot wound. The client's family arrives at the ED and is taken to a private area. The following tasks must be completed by a multidisciplinary team comprised of a physician, registered nurse, and social worker who interact with the family. Which tasks are the priority nursing responsibilities? Select all that apply.

Maintaining organs that may be used for transplantation Accompanying the client's family for viewing of the body Providing support and therapeutic touch as needed

Based on the child's current condition, the child is at highest risk for __________. In addition, the child will need interventions to prevent further injury from the caregiver's suspected __________.

Infection Physical abuse

The pilot study was successful and the results were positive. The committee took the results to the stakeholders and the new client discharge protocol was approved. What considerations need to be taken at this step in the process? Select all that apply​.

Information technology support​ Cost of implementing the protocol Education of staff How to monitor progress​

A nurse is caring for a client with a history of drug abuse. The charge nurse overhears a conversation at the nurses' station where one nurse says to the other, "My client is constantly requesting pain medication, so I administered normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority?

Instruct the nurse to notify the healthcare provider about the lack of pain relief.

When attempting to implement the new discharge process with nursing staff, which barriers might be encountered by the committee? Select all that apply.

Lack of resources Time constraints Uncertainty about the new process Inadequate staffing

Identify additional information that should be included in the hand-off report from the emergency department (ED) nurse to the surgical nurse. Click to select and drag the correct response to the box provided.

Last oral intake Current blood pressure Level of consciousness Pain assessment

Highlight the assessment findings that require immediate follow-up by the nurse.​

Left hand extending up the lower forearm has glove-like redness with four large fluid filled blisters Several small, sharply-demarcated lesions with eschar

Identify the correct order in which the nurse should see the assigned clients. Click to select and arrange each client in order of nursing priority.

Leukin Juniper Strykner Speltzner

When admitting a client to an acute care facility (hospital), the nurse addresses safe keeping of the client's belongings. Which actions does the nurse need to complete? Select all that apply.

List the belongings in the electronic health record (EHR) with as much detail as possible for accuracy. Note the disposition of items on the inventory within the electronic health record. Document that the client was informed of the valuables policy and elected to dispose of items as noted on the valuables inventory. Ask the client what belongings they brought with them.

Why is evidence-based practice (EBP) important to nursing care? Select all that apply.

Nursing care is more efficient when ineffective processes are replaced. Clients want evidence-based information to make decisions. Client outcomes are better when evidence is used as a basis for practice. Using EBP results in fewer errors in decision making.

An adolescent has been admitted for the second time to treat diabetic ketoacidosis (DKA). Which referral services should the nurse initiate? Select all that apply.

Nutritionist to assess diet Psychiatric nurse liaison to assess reasons for noncompliance Visiting nurses to arrange for directly observed therapy Social worker to see if the client can afford the medications

A client presents to the emergency department with upper gastrointestinal bleeding and abdominal pain. The client is sweating and appears to be in moderate distress. Which nursing action is the priority?

Obtain vital signs

The client's spiritual leader arrives at the hospital and inquires about the client's condition. The nurse does not provide information but instead directs the visitor to sit with the family in the waiting room. This is an example of the nurse protecting the client's __________. The provider determines that the client needs a chest tube inserted due to a hemothorax. Before beginning the procedure, the nurse should verify the presence of a signed __________. The client informs the nurse that they do not want a blood transfusion for religious reasons. The nurse contacts the provider with this information. This is an example of __________. The client's advance directive does not address ventilatory support which the client needs. The partner wants the client intubated, while the durable power of attorney refuses to consent. This situation represents an ethical __________.

Privacy Consent Advocacy Dilemma

The __________ and confidentiality of data in clinical information systems, as well as the security and __________ of hospital and other health information, are protected by __________ and procedures that have been created and implemented by healthcare facilities.

Privacy Safety Policies

What actions should the nurse take? Select all that apply.

Request charge nurse to clarify prescriptions on Speltzner and discharge. Delegate sputum collection for Strykner to the licensed practical/vocational nurse. Explain to Strykner the nurse cannot discuss other clients.

A client with chest pain arrives at the emergency department via an ambulance. Immediately upon arrival, the client states, "I want to go home now!" Which actions should the nurse take? Select all that apply.

Request the client sign a form relieving the hospital from all liability.​ Document the client's intent to leave the facility against medical advice (AMA).​ Explain to the client the risks involved if they choose to leave.​

A 51-year-old male client presents to the emergency department (ED) after being struck by a car while crossing the street. ​Review the electronic health record and then answer the questions. Which assessment finding is the priority?

Respiratory assessment​

A nurse is preparing to administer a unit of packed red blood cells to a female client with hemoglobin of 6.9 g/dL (reference range: 12- 16 g/dL). The unit secretary retrieved the blood 25 minutes ago. When entering the client's room, the nurse notes that the client's peripheral intravenous (IV) device is not patent and is unsuccessful at inserting the new IV. What should the nurse do next?

Return the blood to the blood bank.

The referral process is a __________ approach to help clients use services or resources, with the aim of promoting __________ and enhancing self-care and __________.​

Systemic Wellness Quality

The nurse uses clinical decision making to keep __________ focused on __________.​

The healthcare team Actions that move the client towards health

During one of the first meetings after the data mining started, a staff member asked how they knew for sure that the data collected was "quality" evidence. The analyst assured the staff member and committee that it was. How is quality determined?​

Use metrics such as consistency and integrity​.

The nurse is providing discharge teaching to a client who is hearing impaired. Which actions should the nurse take? Select all that apply.

Use printed materials with pictures and illustrations​. Ensure there is adequate lighting in the room​. Sit directly in front of the client while speaking​. Encourage the client to repeat back the instructions​.