Leadership

A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?

"Change-of-shift report can be given at the client's bedside." Change-of-shift report is often given at the client's bedside to help protect the client's privacy. This allows the client to be involved with their care. The nurse should avoid giving report in public areas, such as in the hallway. Wrong "I can provide client information over the phone if the caller identifies themselves as family." Providing client information over the phone to a person who identifies themselves as family can be considered invasion of privacy, which is a quasi-intentional tort. Clients must authorize who can obtain their information. Most facilities have an established plan for managing phone calls, such as using a passcode to obtain information. "A client cannot see their medical record because it is considered to be property of the facility." HIPAA rules provide the client with the right to consent to the use and disclosure of their protected health information. It also provides the right for the client to inspect and copy their medical record as well as amend any mistaken or incomplete information. "Access to client information is limited to direct care providers." MY ANSWER Access to client information is limited to those who need to know the information, which can include direct care providers and administrative personnel.

Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an AP?

"Check the urinary output at 1100 for John Doe and report it to me immediately." MY ANSWER This instruction follows the Five Rights of Delegation by including the requirements for right direction/communication: the data to collect, client-specific information, a timeline for collection, and the expectation for communicating the findings back to the nurse. Wrong "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122." The nurse should practice right direction/communication as part of the Five Rights of Delegation. This statement does not indicate details for communicating findings back to the nurse. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438." The nurse should practice right direction/communication as part of the Five Rights of Delegation. This statement does not indicate a timeline for measuring the drainage or what qualifies "excessive" drainage. "Please notify me of any clients whose vital signs or blood glucose levels are significant." The nurse should practice right direction/communication as part of the Five Rights of Delegation. This statement does not indicate a timeline for collecting data or what "significant" means.

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

Pick up the first sterile glove by grasping the folded cuff edge. MY ANSWER The nurse should pick up the first sterile glove by grasping the folded cuff edge, which is the palmar side, to prevent contamination of the outside of the glove. Wrong Open the top flap of the sterile package towards the body. The nurse should open the top flap of the sterile package away from the body. Maintain a 1.25 cm (0.5 in) border around the edges of the sterile field. The nurse should maintain a 2.5 cm (1 in) border around the edges of the sterile field. Remove soiled dressings using sterile gloves. The nurse should use clean gloves to remove soiled dressings.

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following action should the team take to evaluate the effectiveness of the plan?

Compare data from clients' records regarding skin integrity with established criteria. Chart audits are an efficient and accurate way to measure if a change in a performance improvement indicator has occurred after an intervention is implemented. Wrong Measure staff attendance at an educational program on managing pressure injuries. This is an example of a process audit and does not measure changes in outcomes. Interview clients regarding their satisfaction with their care. MY ANSWER While client satisfaction with care is an important indicator, it is not a reliable method for evaluating the effectiveness of the plan. Monitor use of supplies used to prevent pressure injuries. While this might yield some information about cost, it does not measure the actual outcomes.

A nurse is receiving report from the AP assigned to the nurses group of clients. Which of the following statements from the EAP indicates the client the nurse should assess first

"The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void." Not voiding for 6 to 8 hr after indwelling urinary catheter removal indicates this client is at risk for urinary retention, which can cause a urinary tract infection. Overdistention of the bladder can cause damage to the mucosa. Therefore, the nurse should assess this client first and report findings to the provider. Wrong "The client who had abdominal surgery 3 days ago is reporting feeling constipated." MY ANSWER The nurse should assess the client who is feeling constipated 3 days postoperatively to determine treatment options; however, the nurse should assess another client first. Decreased peristalsis is an expected postoperative finding. "The client who had the hip replacement reports pain as 4 on a scale of 0 to 10." The nurse should assess the client who reports pain as 4 on a 0 to 10 numeric pain scale to determine treatment options; however, the nurse should assess another client first. The client who is scheduled for discharge today states they are ready to sign their paperwork."The nurse should assess the client who is scheduled for discharge today to complete discharge teaching; however, the nurse should assess another client first.

A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?

Advise the client to install grab bars in the bathroom at home. MY ANSWER The nurse should advise the client to install grab bars in the bathroom at home to reduce the risk for falls. Wrong Advise the client to install grab bars in the bathroom at home. MY ANSWER The nurse should advise the client to install grab bars in the bathroom at home to reduce the risk for falls. Encourage the client to allow a home care aide to perform ADLs for them. Encouraging the client to allow the home care aide to perform their ADLs discourages independence. Contact hospice to provide follow-up care for the client. A client who has left-sided weakness does not require hospice care. Hospice care is for clients who have a terminal illness.

A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent?

Ask the client to explain the procedure that is being performed. MY ANSWER The nurse should ask the client to explain the procedure that is being performed. This allows the nurse to verify the client's understanding of the information provided by the provider prior to witnessing the client's signature on the consent form. Wrong Verify that the client understands the risks of the surgery. It is the responsibility of the provider to ensure the client has all necessary information about the risks of the surgery in order to make an informed decision and provide consent. Answer the client's questions about the outcomes of the surgery. It is the responsibility of the provider to ensure the client has all necessary information about the outcomes of the surgery in order to make an informed decision and provide consent. Determine if the client understands the benefits of the procedure. It is the responsibility of the provider to ensure the client has all necessary information about the benefits of the surgery in order to make an informed decision and provide consent.

Two nurses on a unit H contend that the other is not doing fair share of work. The conflict is affecting the functioning of the unit. A charge nurse should approach this conflict in which of the following ways?

Explore alternative solutions to address unit workflow with the nurses. MY ANSWER Exploring alternative solutions will allow the nurses to collaborate, which creates a higher probability that the nurses will reach a successful resolution. Wrong Tell the nurses that it is their responsibility to cooperate with coworkers. This response is dismissive of the nurses' concerns. Organize a task force to evaluate the situation. An interpersonal issue between two nurses does not require a task force. The charge nurse should address this issue. Schedule the nurses to work on alternating shifts. This action avoids the issue and might not meet staffing requirements.

A nurse is caring for a client who request pain medication. The nurse fulfills a promise to return with the medication within 15 minutes. The nurse is demonstrating which of the following ethical principles?

Fidelity MY ANSWER The nurse is demonstrating fidelity by returning to the client's room with the medication in a timely manner. Fidelity is an ethical principle in which the nurse's actions are taken to display loyalty and keep a promise made to the client. Wrong BeneficenceBeneficence is an ethical principle in which the nurse's actions are taken to "do good" and promote goodness and kindness. Utility Utility is an ethical principle in which the nurse's actions are taken to bring the most to the greatest number of people, where the good of many will outweigh the needs of an individual client. Justice Justice is an ethical principle in which the nurse's actions are taken to seek fairness, where all clients are treated equally regardless of sex, sexual orientation, religion, ethnicity, disease, or social standing.

A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

Inform the assistive personnel of the client's weight-bearing status. MY ANSWER Assistive personnel can assist clients with ambulation in most cases with appropriate delegation from the nurse. The nurse should inform the AP of postoperative prescriptions for weight-bearing as part of safe care delegation. Wrong Assess the client's incision every 8 hr for the first 48 hr. The nurse should assess the incision every 4 hr during the first postoperative day and every 8 to 12 hr thereafter, depending on facility or surgeon protocol. Instruct the client to cross their legs at the ankles when sitting in a chair. The nurse should instruct the client not to cross their surgical leg beyond the midline to prevent dislocation of the joint. Teach the client's partner to assist the client to flex the hip at least 120° each hour. The nurse should teach the client's partner that the client should not flex their hip more than 90° after surgery to prevent dislocation of the joint.

A nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?

Inform the client of the consequences of refusing the medication. MY ANSWER The nurse should inform the client of the consequences of refusing the medication. It is the client's right to decide whether to take the medication. If the client still refuses after receiving further information, the nurse should waste the medication and document the occurrence in the client's medical record. Wrong Leave the medication on the client's bedside table to take later. The nurse should not leave the medication on the client's bedside table, because it is a safety risk to the client and others. If a client refuses medication, the nurse should discard the medication according to facility protocol. Return in 1 hr to administer the medication. The client has refused the medication; therefore, the nurse should not return 1 hr later to make another attempt to administer the medication. Mix the medication in applesauce to administer to the client. The nurse should not administer medication to the client without the client's consent, as this disregards the client's right to self-determination.

A nurse is caring for a client who reports vomiting and diarrhea for the past six hours. The nurse should identify that which of the following assessments is the priority?

Obtain the client's serum potassium level. MY ANSWER Because vomiting and diarrhea contribute to the loss of potassium through body fluids, the greatest risk to this client is life-threatening cardiac dysrhythmias as a result of hypokalemia; therefore, the nurse should identify that the priority assessment is the client's serum potassium level. Wrong Check the client's urine specific gravity. The nurse should check the client's urine specific gravity to assist in determining the degree of dehydration and to monitor rehydration; however, another assessment is the priority. Measure the client's temperature. The nurse should measure the client's temperature because fluid loss can cause mild hyperthermia; however, another assessment is the priority. Auscultate the client's bowel sounds. The nurse should auscultate the client's bowel sounds to monitor for increased peristalsis; however, another assessment is the priority.

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheter's in the intensive care unit. Which of the following resources should the nurse consult in planning for this policy?

State Nurse Practice Act (NPA) MY ANSWER The nurse should consult the NPA in this situation because the NPA defines the scope and boundaries of professional nursing practice. The NPA provides guidelines for developing standardized procedures within specific facilities where expanded nursing functions have been approved in collaboration with nurses, providers, and administration. Wrong National League for Nursing (NLN) The NLN is a national organization for faculty nurses and leaders in nurse education. It offers faculty development, networking opportunities, testing services, nursing research grants, and public policy initiatives. American Academy of Nursing (AAN)The AAN is a professional organization that generates, synthesizes, and disseminates nursing knowledge to contribute to health policy and practice for the benefit of the public and the nursing profession in general. Agency for Healthcare Research and Quality (AHRQ) The AHRQ is part of the United States Department of Health and Human Services, which supports research and is designed to improve the outcomes and quality of health care.

A nurse is developing a plan of care for a school-aged child whose family is homeless. Which of the following findings should the nurse identify as the priority?

The child has red fissures at the corners of the mouth. Using Maslow's hierarchy of needs, the nurse should determine that the priority finding is red fissures at the corners of the child's mouth. This can indicate a vitamin B deficiency, which is a physiological need. Wrong The child has several small bruises on both legs. MY ANSWER School-age children might have bruises, cuts, or abrasions on their legs due to age-appropriate physical activity. Therefore, another finding is the priority. The child sleeps for about 13 hr each night. Depending on age, a school-age child might sleep between 9 and 13 hr each night. The nurse should encourage effective sleep patterns; however, there is another finding that is the priority. The child is not regularly attending school. The child's irregular school attendance can be attributed to the child's family being homeless. The nurse should address these concerns; however, there is another finding that is the priority.

A nurse on a medical-surgical unit has arrived late to work multiple times over the past several weeks. The nurse manager is planning to use progressive discipline to address this problem. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The first step of the progressive discipline process is counseling the employee. The manager should set up a meeting with the nurse to ensure the nurse understands the expectations of the position. The manager should explain what the nurse must do to correct the behavior. If it continues, the manager should proceed to a written reprimand, which the manager and the nurse must sign to acknowledge that they discussed the issue. If the nurse's performance still does not improve, the manager should proceed with suspension. If the problem continues, the manager should terminate the nurse's employment.

A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care?

The length of the client's stayMY ANSWERThe client's clinical pathway is a standardized approach to assist the nurse to provide cost-effective client care and shorten the length of stay. Wrong The age of the client The client's age is not a component of the clinical pathway and does not assist the nurse in evaluating cost effectiveness of health care. The availability of community support groups Availability of community support groups is not a component of the clinical pathway and does not assist the nurse in evaluating cost effectiveness of health care. The type of insurance the client carries The type of medical insurance the client carries is not a factor in determining cost-effective care.

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?

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.

A nurse is caring for a client who is hospitalized and has expressive aphasia. The client reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. Which of the following responses should the nurse make?

This is a procedure that does not require written informed consent." MY ANSWER The client does not need to sign an informed consent form for insertion of an indwelling urinary catheter. The client gives implied consent by complying with the procedure. Wrong Procedures prescribed by the provider do not require consent." This statement is inaccurate because the client must give informed consent for some procedures that the provider prescribes. You are right. I will discuss this issue with the charge nurse." This statement is inaccurate because the nurse can insert an indwelling urinary catheter if the client gives implied consent. "Would you mind signing the informed consent form for the procedure at this time?" This statement is inaccurate because the nurse can insert an indwelling urinary catheter if the client gives implied consent.

A client who has back pain presented to the ER and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?

"Clients are the experts on their own pain." MY ANSWER This response is appropriate because it indicates the nurse understands that the client's report is the best indicator of pain and is not making any assumptions. Wrong "It sounds like nonpharmacological interventions would be best for this client." Replacing the client's pain medication with nonpharmacological interventions is an unethical practice. The nurse is making an assumption about drug-seeking behavior, which is not an appropriate basis for a decision. "Let's withhold the oxycodone until we can consult with the provider." Withholding a client's pain medication is an unethical practice. The nurse is making an assumption about drug-seeking behavior, which is not an appropriate basis for a decision. "Contact mental health services to arrange for a consultation." There is no data to indicate the client needs a mental health consult. The nurse is making an assumption about drug-seeking behavior, which is not an appropriate basis for a decision.

A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Clients on a mental health unit can refuse their medication." MY ANSWER Regardless of the type of health care facility or admission status, clients maintain the right to refuse medications. Wrong Clients on a mental health unit who are admitted voluntarily cannot leave against medical advice." Clients who are admitted voluntarily can request to leave the facility at any time; however, the provider should explain the risks to the client. If the client is at risk for self-harm, the client might be converted to involuntary status. "A nurse can inform the client about the risks and benefits of electroconvulsive therapy." It is the provider's responsibility to discuss the risks and benefits of electroconvulsive therapy with the client. "A nurse can provide basic treatment information to the client's employer." Providing treatment information to a client's employer without client consent is a breach of the right of client confidentiality.

An AP tells a charge nurse that it is unfair that they have to take care of all the clients who are in continent. Which of the following responses should the charge nurse make?

"I delegate tasks to personnel based on their job descriptions." This response addresses the AP's concerns and provides clear information about the charge nurse's responsibility when delegating tasks. Wrong "Everyone working here has to care for clients who are incontinent." This response is nontherapeutic because it is dismissive of the AP's concerns. "Let's talk about organizing the workflow so you care for fewer of these clients." MY ANSWER This response is inappropriate because the AP does not have the knowledge, skills, and ability to assist with client assignments. "Why do you not want to care for clients who are incontinent?" Asking why the AP does not want to care for clients who are incontinent is a nontherapeutic response that can make the AP feel defensive.

A nurse is caring for a 19 year old client who has just been informed that their cancer has metastasized. The client tells the nurse that they do not want to continue chemotherapy. Which of the following responses should the nurse make?

"I will gather information about palliative care for you." MY ANSWER The nurse is acknowledging the client's right to refuse treatment and is demonstrating support by offering to discuss end-of-life care options. Wrong "I will have the provider discuss treatment options with your parents." A 19-year-old client is legally able to make decisions about their own care. The client has the right to refuse treatment. "I will contact your spiritual advisor to discuss this decision with you." The nurse is making an assumption about the client's religious beliefs and spiritual needs. "I will contact your parents about becoming your designees in your durable power of attorney." A 19-year-old client is legally able to make decisions about their own care. The client has the right to refuse treatment without parental involvement.

A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?

"Your case manager will coordinate the resources you will need." MY ANSWER A case manager coordinates a client's care, including resources for home care. Wrong "A social worker will address your concerns after discharge." This is as an example of minimizing the client's feelings. The client is asking for help now. A social worker addresses financial concerns about affording care. "You should plan to go to a skilled nursing facility after discharge." This is an example of giving premature advice to a client. While the client has indicated concerns about performing self-care, a skilled nursing facility is necessary after the client is no longer able to care for himself and requires the care of a nurse. You will need hospice care until you feel stronger." This is an example of giving premature advice to the client. Hospice care is available at home and is meant to manage manifestations and provide comfort, not to promote rehabilitation or cure the illness.

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 from a medical unit can care for this client because the surgical dressing is usually left in place for 48 to 72 hr, so the residual limb does not require special care at this time. Wrong A client who has a fractured femur with a new cast An orthopedic nurse should care for this client because they have experiential knowledge of the care of a new cast and monitoring required to safely care for this client. A client who had a total hip arthroplasty 3 days ago MY ANSWER An orthopedic nurse should care for this client because they have experiential knowledge of the postoperative restrictions for hip arthroplasty required to safely care for this client. A client who is in balanced skeletal traction An orthopedic nurse should care for this client because they have experiential knowledge of the care of balanced skeletal traction required to safely care for this client.

A nurse is caring for four clients. Which of the following assessment findings is the priority?

A client who has a femur fracture and reports feeling short of breath MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is a client who has a femur fracture and reports feeling short of breath. Clients who have a fracture can develop a deep-vein thrombosis, which can lead to pulmonary embolism. Wrong A client who has facial drooping following a stroke 8 hr ago Facial drooping 8 hr following a stroke is nonurgent because it is an expected finding. Therefore, there is another finding that is the priority. A client who had an appendectomy 12 hr ago and reports pain as 5 on a scale of 0 to 10 Presence of pain is nonurgent because it is an expected finding for a client following surgery. Therefore, there is another finding that is the priority. A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing The nurse should continue to monitor for the presence of serosanguineous drainage on the dressing because drainage exceeding 5 days can be an indication of dehiscence. However, there is another finding that is the priority.

A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the curse recommend the provider evaluate first?

A client who has a sucking chest wound MY ANSWER A client who has a sucking chest wound has an immediate threat to life and requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend the provider evaluate this client first. Wrong A client who has a 15.2-cm (6-in) laceration to the scalp with clotted blood visible A client who has a 15.2-cm (6-in) laceration with clotted blood visible does not have an immediate threat to life and can wait more than 2 hr before receiving treatment; therefore, the nurse should recommend the provider evaluate a different client first. A client who has a comminuted fracture of the femur A client who has a comminuted fracture of the femur does not have an immediate threat to life and can wait up to 2 hr before receiving treatment; therefore, the nurse should recommend the provider evaluate a different client first. A client who has a penetrating head injury and respiratory rate of 4/min A client who has a penetrating head injury and a respiratory rate of 4/min has a minimal chance of survival even with intervention; therefore, the nurse should recommend the provider evaluate a different client first.

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

A nurse is photocopying their assigned client's diagnostic test results. MY ANSWER Photocopying diagnostic test results is a breach of the client's confidentiality and privacy. Wrong An assistive personnel (AP) documents a client's vital signs on the client's paper-based graphic record. Documenting vital signs is within the AP's range of function. The unit secretary faxes a client's laboratory results to the provider.Faxing diagnostic test results to the provider is not a breach of confidentiality and privacy if the staff uses security measures, such as verifying the number before sending information, and using a cover sheet. An RN stays with a client who is reading the medical records that were requested.Agency policy might require the nurse to stay with the client who has a legal right to access and read their own medical record.

A client on a general surgical unit tells the nurse that staff members are not answering the call light promptly. The client request to be transferred to another unit. Which of the following actions should the nurse take first?

Ask the client to verbalize their expectations. The first action the nurse should take using the nursing process is to assess; therefore, the first action the nurse should take is to assess the client's feelings and clarify expectations. Wrong Notify the charge nurse of the client's request for transfer. MY ANSWER The nurse should notify the charge nurse of the client's request to advocate for the client, but this is not the first action the nurse should take. Assure the client that their concern has been shared with the staff. The nurse should assure the client that appropriate action will occur to demonstrate caring, but this is not the first action the nurse should take. Tell the client that future calls will be answered in a timely manner. The nurse should assure the client that in the future the nurses will answer their calls in a timely manner to demonstrate caring, but this is not the first action the nurse should take.

A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first?

Assist clients who are in immediate danger to a safe location. MY ANSWER The greatest risk to clients is injury from the fire. Therefore, the first action the nurse should take is to move clients who are in immediate danger to a safe location. Wrong Close doors and windows on the unit. The nurse should close the doors and windows on the unit to prevent the fire from spreading, but there is another action the nurse should take first. Attempt to extinguish the fire using an ABC fire extinguisher. The nurse should attempt to extinguish the fire using a universal fire extinguisher, but there is another action the nurse should take first. Discontinue oxygen use for clients who can breathe without it. The nurse should discontinue oxygen for clients who can breathe without it to prevent spread of the fire, but there is another action the nurse should take first.

A nurse is caring for a client who is terminally ill and receiving nutritional support. The client's adult children disagree about continuing nutritional support. The dilemma is referred to the ethics committee. Which of the following actions should the nurse expect the committee to take? Assist in weighing the options involved in the decision

Assist in weighing the options involved in the decision. MY ANSWER Ethics committees are members of the interprofessional team who assist with problem solving related to ethical dilemmas. The ethics committee examines all of the facts and provides support for the clients and caregivers. Wrong Provide a legal representative for the family. Although legal experts might participate in ethics committees, it is not the role of the ethics committee to offer legal support. Recommend the best course of action for the client. The ethics committee highlights important considerations for each case and provides support for the client and caregivers, but it does not recommend a best course of action. Decide how the nursing team should resolve the dilemma. Ethics committees do not impose a specific decision. The decision maker in this case, and in many ethical dilemmas, is the client or the family.

A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an AP?

Determine a client's intake and output. MY ANSWER The nurse can delegate determining a client's intake and output to an AP, as this does not require the use of the nursing process and is within the range of function of an AP. Wrong Provide a status update to a client's family member. Providing a status update to a client's family member is not within the range of function of an AP. This is the responsibility of the nurse. Administer subcutaneous medications to a client. Administering subcutaneous medication requires special training and is not within the range of function of an AP. Instruct a client how to take their blood pressure. Instructing a client on how to take their blood pressure is not within the range of function of an AP. This is the responsibility of the nurse.

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Determine goals and objectives. According to evidence-based practice, the nurse attempting to make a change or revision to a policy should first develop the initial plan and then determine goals and objectives. Objectives define strategies or implementation steps to attain the identified goals. Wrong Set target dates for completion. The nurse should set target dates for completion as a later step in the policy revision process; evidence-based practice indicates that another action is the priority. Identify areas of support. MY ANSWER The nurse should identify areas of support as a later step in the policy revision process; evidence-based practice indicates that another action is the priority. Implement recommended strategies. The nurse should implement recommended strategies as a later step in the policy revision process; evidence-based practice indicates that another action is the priority.

A nurse on a MedSurg unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

Discuss the client's feelings about the procedure. MY ANSWER The nurse should encourage the client to discuss any feelings or concerns about the procedure. Wrong Emphasize the benefits of having the procedure. This is a nontherapeutic response that is giving the nurse's approval. Ask if the client has discussed the decision with their partner. This is a nontherapeutic response that is dismissive of the client's concerns. Provide information about alternate birth control methods. This is a nontherapeutic response that is dismissive of the client's concerns.

A charge nurse recognizes a trend of poor attendance at monthly staff meetings. To address this issue, which of the following actions should the nurse charge nurse take first?

Explore the reasons that staff are not attending the meetings.MY ANSWERAccording to evidence-based practice, the nurse should first identify the reasons that staff are not attending the meetings. This allows the nurse to address the specific problems identified by the staff. Wrong Write a memorandum emphasizing the importance of attending staff meetings. The nurse should write a memo emphasizing the importance of attending staff meetings. However, evidence-based practice indicates that the nurse should take a different action first. Appoint a task force to promote attendance at the meetings. Appointing a task force to promote attendance at meetings is important to remind the staff about the meetings. However, evidence-based practice indicates that the nurse should take a different action first. Reduce the number of meetings the staff are required to attend. Reducing the number of meetings the staff are required to attend can improve attendance. However, evidence-based practice indicates that the nurse should take a different action first.

A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behavior should the charge nurse identify as an indication that the staff nurse might be working while impaired?

Frequent use of restroom MY ANSWER Frequent use of the restroom can indicate that the nurse might be working while impaired. Other indications can include frequent errors, mood swings, inability to focus, and excessive wasting of controlled substances. Wrong Spends free time conversing with other staff at the nurses' station Spending free time conversing with other staff does not indicate that the staff nurse is working while impaired. Isolating oneself from others can be an indication of impairment. Asks other nurses to administer pain medication for their clients Displaying an increased interest in controlled substances or offering to administer pain medication for other clients can indicate the staff nurse is working while impaired. Delegates tasks to assistive personnel Delegating tasks to assistive personnel is an effective time management technique and does not indicate that the nurse is working while impaired. Making poor judgments can be an indication of impairment.

A charge nurse is observing a newly licensed nurses use of time management skills. Which of the following actions by the newly licensed nurse indicates effective use of the skill?

Groups tasks that are in the same location MY ANSWER The newly licensed nurse should group tasks that are in the same location to effectively use time. This prevents the nurse from going back and forth from one area to another. This action promotes effective time-management skills. Wrong Documents client tasks at the end of the shift The newly licensed nurse should document client tasks as they are completed throughout the entire shift. Documenting at the end of the shift can lead to inaccuracy of the documentation and possible error. Gathers supplies as needed while completing an activity The newly licensed nurse should think about the steps of an activity ahead of time and gather all the needed supplies before starting the task. This action promotes effective time-management skills. Skips breaks throughout the day to complete work on time The newly licensed nurse should not skip breaks throughout the shift to complete work. It is important for the nurse to take breaks as well as eat lunch. This allows the nurse to refresh physically and mentally to prepare for the rest of the shift.

A nurse is planning the discharge of a newborn who requires apnea monitoring at home. To which of the following community agencies should the nurse anticipate referring the guardian of the newborn? Home health

Home health MY ANSWER A home health agency can provide nurses who will visit the home and help the guardian learn necessary skills, as well as assess the progress of the infant. Wrong Child protective services Child protective services agencies are appropriate resources to use when child abuse or endangerment is suspected. Public health A public health agency's primary focus is on the health of a community and not that of individual clients. Women, Infants, and Children Women, Infants, and Children (WIC) provides nutritional subsidies to pregnant and lactating mothers, and infants and children up to age 5.

A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take?

Identify stable clients for transfer to a surgical unit. It is within the charge nurse's scope of practice to identify stable clients for transfer to a surgical unit. This action will enable the facility to do the most good for the greatest number of clients. Wrong Take extra wheelchairs to the emergency department. The charge nurse should delegate an assistive personnel to take extra wheelchairs to the emergency department, if needed. Send PACU assistive personnel to assist with triage. It is not within an assistive personnel's range of function to perform triage. Report to the command center for further instructions. MY ANSWER The PACU charge nurse should plan to remain in the PACU to coordinate the care of anticipated large numbers of postsurgical clients.

A nurse manager needs to address increased rate of client med errors. Which of the following strategies represents an authoritarian approach to managing the issue?

Inform the staff of the penalties that can result from medication errors. MY ANSWER The nurse manager is using penalties to promote behavior change; this is characteristic of authoritarian leadership. Wrong Encourage the staff to have two nurses verify medication orders to prevent errors. The nurse manager is using a democratic leadership style by offering constructive feedback. Provide a suggestion box for the staff to submit ideas for error prevention. The nurse manager is using a laissez-faire leadership approach; this places emphasis on group decision making. Ask three experienced nurses to help investigate common causes of the errors. The nurse manager is using a democratic leadership style when consulting others to help the decision-making process.

A nurse manager is auditing client charts and identifies an increase in ventilator-associated pneumonia (VAP). Which of the following actions should the nurse manager take?

Notify the quality improvement team. MY ANSWER The nurse should report any unusual occurrences or trends, such as VAP within the unit, to the quality improvement team. The quality improvement team will analyze and evaluate the data to implement needed changes. Wrong Fill out an incident report. The nurse should complete an incident report to describe events that involve a single, unusual client or visitor situation. Alert central supply. It is possible that a problem with the ventilator tubing or accessories is causing the trend in VAP. Other hospital personnel will investigate the cause and notify central supply at a later time, if needed. Report the findings to the hospital ethics committee. The nurse manager should not report a trend in VAP to the ethics committee. The hospital ethics committee assists with difficult or ambiguous value issues related to client care.

A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes. The nurse should recommend a referral for the client to which of the following members of the inter-professional team?

Occupational therapist MY ANSWER The nurse should recommend a referral to an occupational therapist for a client who has osteoarthritis and reports difficulty with ADLs, such as buttoning clothing. Occupational therapy can assist the client with exercises to help the client complete these tasks. Wrong Podiatrist A podiatrist specializes in the care of clients who have conditions involving the feet and ankles. Social worker A social worker specializes in counseling and care of clients who have concerns related to psychosocial needs, such as financial or domestic issues. Paramedical technologist A paramedical technologist specializes in the performance of medical procedures such as phlebotomy or ECG monitoring.

A nurse manager finds that there has been an increase in UTIs on the unit. To address this problem, which of the following actions should the nurse manager take first?

Perform a chart review to gather data about the clients who developed infections. MY ANSWER The first action the nurse manager should take when using the nursing process is to assess. The nurse should conduct a chart audit to gain important information about the factors responsible for the increased incidences of infection. Wrong Conduct an in-service that reviews proper catheter insertion and maintenance. The nurse manager should conduct an in-service to reinforce correct catheter procedure to prevent future incidences of urinary tract infections; however, there is another action the nurse manager should take first. Observe each staff nurse perform a urinary catheter insertion. The nurse manager should observe each staff nurse performing a urinary catheter insertion and provide correction when needed to ensure appropriate technique is used; however, there is another action the nurse manager should take first. Require completion of a self-paced instruction program. The nurse manager should require the nurses to complete a self-paced instruction program to reinforce correct catheter procedure; however, there is another action the nurse manager should take first.

A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplant. Which of the following instructions should the nurse manager include in the teaching?

Place clients in positive-pressure airflow rooms.MY ANSWERThe nurse should place a client who requires protective environment precautions following a stem cell transplant in a private, positive-pressure airflow room. The room air is filtered through a HEPA filter and the airflow rate is set at more than 12 air exchanges each hour. Wrong Wear an N95 respirator mask while caring for these clients. Health care personnel should wear an N95 respirator mask while caring for clients who require airborne precautions. These masks protect the nurse from inhaling contaminated droplet nuclei. Obtain a rectal temperature on clients every 4 hr. The nurse should choose another route for measuring temperature to avoid introducing microorganisms that can cause an infection. Assign two clients who have had a stem cell transplant to the same room. The nurse should only cohort two clients in a semi-private room if they are infected with the same pathogen. The nurse should assign clients who have had a stem cell transplant in private rooms to reduce the risk of infection.

A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following action should the charge nurse expect the newly licensed nurse to take?

Place the client in a dorsal recumbent position for the examination. To prepare the client for a routine abdominal assessment, the nurse should place the client in a dorsal recumbent or supine position and ensure that the client relaxes her abdominal muscles. Wrong Auscultate for vascular bruits with the diaphragm of the stethoscope. The charge nurse should expect the newly licensed nurse to use the bell of the stethoscope to auscultate for vascular bruits. Begin the assessment by using light palpation over the abdomen. MY ANSWER The charge nurse should expect the newly licensed nurse to begin the assessment by inspecting the client's abdomen for changes in color, contour, and symmetry. Ensure that the client has a full bladder before beginning the procedure. The charge nurse should expect the newly licensed nurse to have the client empty their bladder before beginning the procedure for optimal examination of the abdomen.

A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first visit the client who has which of the following laboratory values?

Platelets 100,000/mm3 MY ANSWER A client who has a platelet count of 100,000/mm3 is unstable because this value is below the expected reference range of 150,000 to 400,000/mm3, which places the client at risk for bleeding; therefore, the nurse should visit this client first. Wrong Digoxin 1.0 ng/mL A client with a digoxin level of 1.0 ng/mL is stable because this value is within the expected reference range of 0.8 to 2 ng/mL; therefore, the nurse should visit another client first. WBC 6,000/mm3 A client who has a WBC count of 6,000/mm3 is stable because this value is within the expected reference range of 5,000 to 10,000/mm3; therefore, the nurse should visit another client first. Serum potassium 4.0 mEq/L A client who has a serum potassium level of 4.0 mEq/L is stable because this value is within the expected reference range of 3.5 to 5.0 mEq/L; therefore, the nurse should visit another client first.

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a n LPN?

Provide an enteral feeding to a client who has Crohn's disease. MY ANSWER Administration of an enteral feeding is within the scope of practice of an LPN; therefore, it is appropriate for the charge nurse to assign this task to an LPN. Wrong Determine the swallowing ability of a client who has had a stroke. The nurse should plan to initiate a referral to a speech-language pathologist to determine the client's swallowing ability following a stroke, and keep the client NPO to prevent aspiration. Develop a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should have an RN develop a teaching plan for a client. An LPN can reinforce teaching from pre-developed materials. Weigh a client who is 3 days postoperative following coronary artery bypass grafting. The nurse should plan to have an assistive personnel (AP) obtain a weight on a client who is stable. This improves care efficiency by allowing licensed personnel more time to focus on specialized tasks that an AP cannot perform.

A hospice nurse is planning care for a client who does not have advance directives. Which of the following intervention should the nurse include in the plan of care

Provide the client with information about advance directives. MY ANSWER Health care providers must offer information to clients regarding their rights to make decisions about their care. Wrong Encourage the client to contact an attorney to create advance directives. Although some states may require an attorney to review advance directives, it is the client's responsibility to create their own advance directives. Inform the client that they will need a relative to witness their advance directives. Although advance directives require a witness, the witness does not need to be related to the client. In some states, relatives cannot act as a witness for advance directives. Tell the client that The Joint Commission requires clients to have advance directives. The Joint Commission does not require the client to have advance directives. However, the Patient Self-Determination Act requires that the nurse ask if the client has advance directives.

A nurse is reviewing safe use of a wheelchair with a group of APs. Which of the following instructions should the nurse include?

Raise the footplates of the wheelchair before transferring the client. MY ANSWER The nurse should raise the footplates of the wheelchair before transferring the client to prevent injury. Wrong Lock the brake on one wheel of the chair when transferring the client. The nurse should lock the brakes on both wheels when transferring the client. Push the wheelchair into the elevator with the front wheels first. The nurse should back the wheelchair into the elevator with the rear wheels first to prevent injury. Stand behind the wheelchair when moving a client down a ramp. The nurse should stand between the wheelchair and the bottom of the incline to provide better control of the wheelchair by keeping weight close to the body. This position allows the nurse to use their arms and legs rather than their back, which will prevent injury.

A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

Receiving moderate sedation MY ANSWER The nurse should verify that the client has given informed consent prior to receiving moderate sedation because this involves anesthesia. Wrong Removal of staples from a surgical wound Removal of staples from a surgical wound does not require informed consent, because it is a low-risk procedure covered under implied consent. Providing a sputum specimen Providing a sputum specimen does not require informed consent, because it is a low-risk procedure covered under implied consent. Collection of a blood specimen for ABGs Collecting a blood specimen for ABGs does not require informed consent, because it is a low-risk procedure covered under implied consent.

A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

Remind the staff members that this is a breach of confidentiality. MY ANSWER When using the urgent vs nonurgent approach to client care, the nurse determines that the first action is to intervene immediately to prevent any further breach in confidentiality. Wrong Discuss the issue with the nurse manager. Discussing the issue with the nurse manager is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority. Request that an administrative restriction be placed on the client's record access. Requesting that an administrative restriction be placed on the client's record access is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority. Prepare a memo for the facility ethics committee. Preparing a memo for the facility ethics committee is nonurgent because this action does not stop the occurring breach of confidentiality; therefore, there is another action that is the nurse's priority.

A nurse asks a newly hired a P to remove a clients indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task

Review the AP's skill competency checklist. MY ANSWER A review of the AP's checklist should validate that they have demonstrated the ability to safely perform the procedure. Wrong Show the AP how to remove an indwelling urinary catheter.Showing an AP how to perform a skill does not ensure the AP is competent to perform the task. Ask the AP if they know how to remove an indwelling urinary catheter. Asking an AP if they can perform the task does not provide evidence of competency to perform the task. Pair the newly hired AP with an experienced AP. Pairing the newly hired AP with an experienced AP does not provide evidence of competency to perform the task.

A nurse is caring for a client who is comatose. The client has a LivingWell that declines the use of artificial enteral nutrition as a life sustaining measure, but the clients family has requested that staff begin to feedings. Which of the following actions should the nurse take?

Review the client's request with the family. MY ANSWER The client's living will states that artificial enteral feedings should not be allowed, and the nurse should review the client's request with the family. Staff members should use the client's living will as the guide for treatment unless a durable power of attorney for health care has been created. Wrong Insert the tube and begin feedings per the family's request. The client's living will states that artificial enteral feedings should not be allowed. The nurse should respect the client's request and advocate for the client. Ask the provider to discuss the issue with the family. The client's living will states that artificial enteral feedings should not be allowed. Staff members should use this directive as the guide for treatment unless a durable power of attorney for health care has been created. Report the dilemma to the facility's dietitian. Because the client has a living will, this issue is not appropriate for the dietitian to review.

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 these changes. Which of the following action should the charge nurse take?

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. Peers can serve as change agents and encourage others to embrace the changes. Wrong Redirect the conversation when staff members make negative comments about the changes is incorrect. The charge nurse should give staff members who oppose the change the opportunity to verbalize their objections and thereby discuss possible solutions. 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 case manager is planning an interprofessional conference for a client who is 3 days postop following an ORIF of the right hip. Which of the following concerns is the priority for discussion at the conference?

The client refuses to attend physical therapy sessions. The greatest risk to this client is postoperative complications due to immobility, such as atelectasis or pneumonia; therefore, the priority for discussion is the client's refusal to participate in physical therapy. Wrong The client does not have transportation for discharge home. The nurse should discuss the client's lack of transportation to identify possible alternative transportation; however, another client finding is the priority for discussion. The client's home health nurse has not completed the home assessment. The nurse should notify the interdisciplinary team that the home assessment has not been completed so that additional plans can be made. However, another client finding is the priority for discussion. The client describes feelings of depression after family visits. MY ANSWER The nurse should discuss the client's feelings of depression to plan for appropriate psychosocial interventions. However, another client finding is the priority for discussion.

A nurse is caring for a client who is three days postop following open heart surgery and will be transferred to the medical surgical unit. Which of the following information to the should the nurse include in the verbal report?

The client's level of consciousness MY ANSWER The nurse should include objective data regarding the client's current consciousness status in the verbal report. Wrong The client's dressing change schedule The nurse should not include routine care procedures in the verbal report The client's vital signs from the previous shift The nurse should only include vital signs from the current shift in the verbal report. he client's occupation The nurse should only include essential background information as it relates to the client's care in the verbal report.

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

The nurse places the sterile package with the top flap opening away from the body. MY ANSWER The nurse should place the sterile package on a flat surface so that the top flap opens away from the body. This prevents the contents of the sterile package from becoming contaminated. Wrong The nurse pinches the flap on the inside of the package first to open it. The nurse should pinch the flap on the outside of the package first to open it. The nurse reaches over the package to open the left flap.The nurse should open the left flap of the package with the left hand. This prevents the nurse from reaching over the package and contaminating the contents of the package. The nurse pulls the last flap of the package away from the body. The nurse should pull the last flap of the package toward the body by pulling the corner down. This prevents the contents of the package from becoming contaminated.

A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?

Wear an N95 respirator mask when in the client's room. MY ANSWER The nurse should wear an N95 respirator mask when caring for clients who have suspected pulmonary tuberculosis. Wrong Wear a surgical mask when taking the client out of the room. The client should only leave the room for essential clinical reasons and when this occurs, the nurse should place a surgical mask on the client. Place the client in a room with positive-pressure airflow. The nurse should place the client who has suspected pulmonary tuberculosis in a room with negative-pressure airflow. Place the client on droplet precautions.The nurse should initiate airborne precautions for a client who has suspected pulmonary tuberculosis.