Leadership Dynamic Quiz

A nurse is caring for a client who has cancer. The client tells the nurse he does not want any more chemotherapy treatments. Which of the following responses should the nurse provide?

"I will inform your provider of your decision to discontinue the treatments." The nurse has a duty to respect the client's right to refuse medical treatment. If a client under the nurse's care refuses treatment, the nurse also has a duty to notify the provider, who should give the client information about the consequences, risks, and benefits of refusing therapy.

A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client states, "I don't think I can go through with the surgery after all." Which of the following responses should the nurse provide?

"I will let the surgeon know about your decision." The nurse should notify the client's surgeon about her decision regarding the procedure. It is the responsibility of the nurse to be the client's advocate and respect the client's wishes. The client has the right to refuse or change her mind at any time regarding the treatment offered.

A nurse is caring for a client who has a history of severe multiple sclerosis and asks the nurse about completing a living will. Which of the following statements should the nurse make?

"I will provide you with the information you need to complete advance directives." Under the Patient Self-Determination Act, health care institutions are required to provide educational materials advising clients of their rights to make personal wishes known regarding treatment.

A 13-year-old female client tells the charge nurse in the pediatric unit that she does not want the male nurse assigned to care for her. Which of the following responses should the nurse make?

"I'll change the assignment so a female nurse is caring for you today." The client has the right to respect and personal dignity and the ability to participate in decisions regarding her care. The charge nurse should change the assignment when possible to minimize any feelings of loss of control for this client.

A home health nurse is caring for a client who asks about the purpose of a living will. Which of the following statements should the nurse include in the teaching?

"It allows the client to express personal wishes regarding health care decisions." A living will allows the client to specify what aspects of care and treatment are to be accepted or refused in the event that the client can no longer communicate those decisions.

A nurse is transporting a client to the surgical suite for a procedure. The client tells the nurse he no longer wants to have the surgery. Which of the following responses should the nurse make?

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

A nurse is providing teaching to a client about organ donation. Which of the following statements by the client indicates an understanding of the teaching?

"People age 18 and over have the right to decide to make an organ donation." Under the Uniform Anatomical Gift Act, individuals must be at least 18 years or older to make an anatomical gift.

A nurse is providing teaching for new parents on safe sleeping recommendations to reduce the risk of sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?

"Room sharing is recommended while the infant sleeps." Sharing a room during sleep has been found to decrease the incidence of SIDS. However, infants should have their own sleep space, such as a crib or bassinet. Bed sharing is not recommended.

A charge nurse is reviewing the Code of Ethics for Nurses during a staff meeting. Which of the following statements should the charge nurse include in the teaching?

"The Code of Ethics for Nurses is a guide for professional actions." The American Nurses Association's Code of Ethics for Nurses is a guide for fulfilling nursing responsibilities in a way that reflects quality in nursing care and upholds the ethical obligations of the nursing profession. It provides a guide for professional actions.

A nurse is planning care for a client following a coronary arterial bypass graft procedure. The nurse places a referral for a case manager to visit the client. Which of the following pieces of information should the nurse share with the client about the role of a case manager?

"The case manager will coordinate and plan your care while you recover from your surgery." The role of the case manager is to coordinate and plan client care, collaborate with other health professionals, and monitor costs and quality of care.

A charge nurse is performing a quality-assurance audit on the documentation of several clients' charts. Which of the following documentation items should the charge nurse identify as a correct entry in the client's medical record?

"The client ambulated for 10 min three times during the shift." The charge nurse should identify that this documentation item reflects objective data about the client's actions.

A nurse is delegating a client care task to an assistive personnel (AP). Which of the following directions should the nurse give the AP?

"This client needs to ambulate using a walker three times today." This direction includes the type of task to be done, the frequency with which the task is to be performed, the duration of the task, and information about the mechanics of ambulating the client.

A group of nurses on a telemetry unit informs a nurse manager of a need to update the cardiac monitoring system to improve arrhythmia detection. Which of the following responses should the nurse manager make?

"This purchase will need to be addressed in the capital budget plan for the unit." The capital budget involves planning for spending related to equipment and major purchases that have a long life of use.

A nurse is delegating tasks to an assistive personnel (AP) for the care of a group of clients. Which of the following directions should the nurse provide?

"Transport the client in room 203 to the radiology department at 1000." This statement observes the rights of delegation. It provides an appropriate task within the AP's scope of practice and offers the right communication by telling the AP which client to transport, where to take the client, and what the time the client needs to be at the radiology department.

A nurse is caring for a client who has breast cancer and is scheduled for a mastectomy. The client tells the nurse she is concerned about how her partner will react to the procedure. Which of the following responses should the nurse make?

"Would you like me to have a member of a breast cancer support group visit you?" The nurse should serve as an advocate for this client. Offering to have a member of a breast cancer support group visit the client allows the client to speak with someone who has been through the same experiences and can assist with the emotional aspects of having a mastectomy.

A nurse is preparing to administer a client's anticoagulant medication. The client states, "I don't like to take this medication. I always have to get my blood checked." Which of the following responses should the nurse make?

"You can refuse the medication. I will notify your provider." The nurse should act as an advocate for the client and acknowledge the client's right to refuse any medication or treatment offered. The nurse should inform the provider of the client's decision.

A charge nurse is teaching a group of clients in an assisted living facility about client rights. Which of the following pieces of information should the charge nurse include in the teaching?

"You can request to review your personal medical records at any time." Clients have the right to request their own medical records and should expect adequate and appropriate care from the facility's personnel.

A nurse is providing discharge teaching about home safety to an older adult client and his family. Which of the following statements should the nurse include in the teaching?

"You should install a handrail on at least one side of the stairs." The nurse should instruct the client and his family to install a handrail on at least one side of the stairs to decrease the potential risk of falls.

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

Accommodation. Accommodation is when one person puts aside personal goals to satisfy the needs of another individual. This nurse is using accommodation in order to resolve the conflict.

A nurse is speaking with the family member of a client who has early Alzheimer's disease. The family member would like to keep the client living at home, but the client requires assistance while the family member is away at work. Which of the following services should the nurse include in the discussion?

Adult day care. Adult day care personnel can provide constant assistance with ADLs while the family member is at work; the client can live at home during the night and evening hours.

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

Advocacy. By following the ethical principle of advocacy, the nurse supports the client in the decisions she makes about her own health care.

A nurse is admitting a client who has measles. This client should be placed in which of the following types of isolation?

Airborne. The nurse should place the client who has measles in airborne isolation. Airborne isolation is used for clients who have infections that can be transmitted through droplets in the air that are smaller than 5 microns. Therefore, the nurse should place the client in a private room that has a negative-pressure airflow with at least 6-12 air exchanges per hour. The nurse should also wear an N95 respirator mask while caring for the client.

A nurse is preparing to provide discharge teaching to an older adult client. Which of the following teaching considerations should the nurse include?

Allow frequent rest periods during teaching. The nurse should allow frequent periods of rest since an older adult client processes information more slowly.

A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at the greatest risk for a complication?

An 80-year-old client who has a fractured hip. The nurse should identify that an 80-year-old client who has a fractured hip is at the greatest risk for a complication due to immobility and a lack of lower-extremity movement, which can lead to deep-vein thrombosis (DVT). DVT is caused by venous stasis and blood clot formation in the vascular system and can lead to pulmonary emboli. The nurse should encourage the client to ambulate as soon as prescribed and implement range-of-motion exercises while on bedrest to prevent DVT.

A nurse is performing a safety audit on all equipment used on the unit. Which of the following items should the nurse identify as a safety hazard?

An electrical cord that is frayed toward the plug. The nurse should identify that an electrical cord that is frayed toward the plug is damaged and should not be used. Using an electrical cord that is damaged can increase the client's risk of acquiring an electrical shock.

A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail of his bed. Which of the following actions should the nurse take?

Ask an assistive personnel to sit with the client. This client is at risk of falling. Having an assistive personnel sit with the client protects him from harm. Then, the nurse can contact the provider to discuss care options for this client (e.g. restraints or placing an audible alarm).

A nurse is working with an assistive personnel (AP) who appears to be under the influence of alcohol during the night shift. Which of the following is the priority action for the nurse?

Ask the nursing supervisor to observe the AP and validate these suspicions. After gathering data, the nurse must first validate these suspicions with another observer, take the appropriate action to safeguard clients, and then document the incident.

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

Assault. The nurse has committed the tort of assault, which is an attempt or threat to touch another person unjustifiably. The nurse threatening to administer an IM injection to the client if she does not take her medication orally is a form of assault.

An RN and a licensed practical nurse (LPN) are caring for a client who has a small bowel obstruction and is NPO with a nasogastric (NG) tube set to continuous suction. Which of the following tasks should the RN perform?

Assess for bowel sounds every 2 hours. Assessments are within the scope of practice for the RN only. While the LPN can also auscultate the client's abdomen for the presence of sounds, only the RN is qualified to evaluate the sounds and qualify them as hypoactive, normal, or hyperactive.

A nurse finds a client standing next to his bed with the side rails raised. The client is visibly confused and not wearing an identification bracelet, and his IV is detached. The client states, "I can't remember my name." After assisting the client back into bed, which of the following actions should the nurse take next?

Assess the client for injury. The nurse should apply the nursing process priority-setting framework when caring for this client. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he/she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision.

Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit. This nurse has limited experience with children. Which of the following actions should the nurse manager take?

Assign a unit nurse to act as a resource for the medical-surgical nurse. Assigning a nurse who usually works on the pediatric unit to assist the medical-surgical nurse will provide consistent support.

A nurse is delegating a task to an assistive personnel (AP). The AP is to transfer a client who has a below-the-knee amputation from a bed to a wheelchair. The AP has never transferred a client with an amputation before. Which of the following actions should the nurse take?

Assist the AP after he has practiced the transfer. The safest way for the nurse to determine if the AP has the knowledge and skill to transfer the client who has an amputation is by having the AP practice and demonstrate the task. By assisting the AP with the first transfer, the nurse helps ensure that delegated care is safely provided.

A nurse has several tasks to complete while preparing a client scheduled for surgery. Which of the following tasks can the nurse delegate to an assistive personnel (AP)?

Assist with placing the client onto the stretcher for transport to the surgical suite. Helping the client onto the stretcher for transport to the surgical suite is a skill that is within the scope of practice for the AP.

A group of providers is participating in a resuscitation effort for a client who is in cardiac arrest. Which of the following types of leadership is required for this group to function most efficiently?

Autocratic Autocratic leadership is most effective in an emergency situation. An autocratic leader will direct and issues commands that are necessary for successful cardiopulmonary resuscitation.

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

Autonomy. Informed consent is based on the ethical principle of autonomy, which is the right to self-determination, independence, and freedom of choice.

A nurse is making a client's bed and finds a capsule of medication in the sheets. Which of the following actions by the nurse is consistent with safe nursing practice? (Select all that apply.)

B. Notifying the provider is correct. The nurse should notify the provider of the finding as a part of the variance reporting process. C. Completing a variance report is correct. The nurse should complete an incident or variance report regarding the occurrence.

A nurse is updating the plan of care for a client who has celiac disease. Which of the following dietary selections should the nurse recommend for the client?

Baked chicken and rice. The nurse should recommend baked chicken and rice as a dietary selection for a client who has celiac disease. Clients who have celiac disease should avoid foods containing gluten.

A nurse enters a client's room and discovers a small fire in a trash can. Which of the following actions should the nurse take first?

Move the client out of the room. The nurse should apply the safety and risk-reduction priority-setting framework when responding to a fire. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, to ensure the safety of the client, the nurse should move the client out of the room.

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

Negligence. Negligence occurs when a client is exposed to an unreasonable risk of injury. Raised side rails help decrease the risk of falling out of bed and are a standard of care for clients who have been identified as at risk of falling.

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

Nonmaleficence. Nonmaleficence is the duty to do no harm and to protect clients from harm by eliminating threats. These actions taken by the nurse are important for the safety of the client by preventing aspiration.

A nurse is assisting with the informed consent process for a client who is scheduled for a below-the-knee amputation. The client asks the nurse, "Why are they making me have this surgery today? I don't understand why they are doing this." Which of the following actions should the nurse take?

Notify the provider of the client's comments. It is the nurse's responsibility to notify the provider if the client has questions or appears not to understand the procedure. The provider is responsible for providing clarification. Informed consent is a legal process by which a client gives written permission for a procedure or treatment

A nurse working at a rehabilitation facility is attending an interdisciplinary team meeting for a client who had a left hemispheric stroke. Which of the following members of the interdisciplinary team should the nurse recommend to assist this client? (Select all that apply.)

Nurse Occupational therapist Speech therapist Physical therapist

A nurse is preparing to give a change-of-shift report to the oncoming nurse. Which of the following pieces of information should the nurse include?

Objective measurements about the client's condition. The nurse should include objective observations and measurements about the client's condition in the report.

A nurse in the emergency department is preparing to obtain informed consent for surgery from a client who received a meperidine hydrochloride IV during transport from a rural hospital. Which of the following actions should the nurse take to obtain consent for surgery?

Obtain consent from a relative of the client. A client who has received meperidine cannot give consent because the medication can alter the ability to understand the consent process. The nurse should obtain consent from a relative of the client. If a relative is unavailable and the surgery is determined to be critical, the surgery can proceed without client consent.

A nurse receives the morning change-of-shift report and delegates several tasks to an assistive personnel (AP) on the team. Which of the following tasks should the nurse instruct the AP to perform first?

Obtain the morning capillary blood glucose tests. The nurse should apply the urgent vs nonurgent priority-setting framework when delegating tasks. The nurse should prioritize urgent needs because they pose more of a threat to the client. The nurse may need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Insulin administration is dependent on the blood glucose levels; therefore, the most urgent task the AP should complete is obtaining the morning capillary blood glucose tests.

A nurse is caring for a client who had a stroke and requires assistance performing ADLs. The nurse should collaborate with which of the following members of the interprofessional care team?

Occupational therapist. An occupational therapist can help clients who have physical limitations or disabilities gain an optimal level of independence in performing ADLs, such as bathing, dressing, grooming, and eating.

A nurse is planning care for a client who has aphasia following a stroke. Which of the following actions should the nurse take?

Offer pictures for the client to point to as an alternative form of communication. The nurse should use alternative forms of communication as needed with the client such as offering pictures the client can point to or a communication board.

A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as part of an effective conference?

Other health care professionals are in attendance at the conference. The nurse should identify that an effective conference should consist of other health care professionals who contribute to the plan of care for goal setting and seek to establish positive client outcomes. The members of the conference consist of the nursing team who should invite other health professionals (e.g. physical therapists, dieticians, and occupational therapists) to contribute to the plan of care.

A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event?

Paralysis of a client's lower extremities occurred following epidural anesthesia. An incident resulting in permanent harm, such as paralysis or death, is a sentinel event. Sentinel events are a high priority and indicate the need for an immediate investigation.

A charge nurse is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)?

Perform a simple dressing change. The nurse should identify that the completion of a simple dressing change is within the AP's range of function. Therefore, the charge nurse can delegate this task to an AP.

A nurse is receiving report on a client who has Clostridium difficile and is being transferred from another unit. Which of the following precautions should the nurse take?

Perform hand hygiene with nonantimicrobial soap and water after client care. The nurse should perform hand hygiene with nonantimicrobial soap and water after providing care for a client who has C. difficile. This spore-forming organism is resistant to alcohol-based soaps and sanitizers.

An RN is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to a licensed practical nurse (LPN)?

Performing tracheostomy suctioning for a client who is stable. An RN may delegate the task of performing tracheostomy suctioning for a client who is stable or whose tracheostomy is not new to the LPN. This task is within the LPN's scope of practice.

A nurse is preparing a client for a lumbar puncture. The client has signed the consent form but tells the nurse that she does not remember what the doctor will do during the procedure. Which of the following actions should the nurse take?

Remind the client that the doctor will insert a needle to get a sample of fluid from her spine. A signed consent form indicates that the provider informed the client about the procedure and that at the time the client understood what to expect. If the client states she does not remember what to expect, the nurse should clarify any details the provider previously gave the client. However, if the client expresses a further lack of understanding or states that the provider did not inform her, the nurse should either notify the charge nurse or call the provider directly.

While caring for a client, a nurse notices that the client's call light cord is frayed. Which of the following actions should the nurse take?

Replace the call light and send the frayed one to the repair department. For client safety, the client needs to have access to a call light to notify the nursing staff for assistance. A frayed cord is an electrical hazard. Removal of a frayed cord is the best way to protect the client from potential electrical shocks or burns.

A school nurse is assessing a child who has multiple bruises on his trunk and extremities. The child reports falling out of a tree 2 days ago. The nurse's assessment findings show patterns of bruising that are not typically sustained during a fall from a tree. Which of the following actions should the nurse take?

Report the findings to local police and social service agencies. Health care providers are required to report suspected child abuse. The nurse's primary concern is the safety of the child. Procedures for reporting differ in various locations, but procedures involve notification of police and social services personnel who can investigate the situation.

A nurse suspects that a coworker may be in an impaired state when providing care to clients. Which of the following actions should the nurse take?

Report these observations to the nurse manager. The nurse who observes an impaired coworker's performance should report this behavior to the nurse manager. If the coworker is found to be impaired, this action will initiate an appropriate intervention and support, and clients will be protected from the actions of an impaired coworker.

A nurse is planning care for a client who is newly admitted to the medical unit. Which of the following health care team members should the nurse plan to consult with regarding the benefit of chest physiotherapy for this client?

Respiratory therapist. The nurse should collaborate with the respiratory therapist and the client's provider to determine if chest physiotherapy (CPT) could benefit the client. A complete respiratory assessment is necessary to confirm the need for CPT.

A nurse manager notes that several staff members are late in completing an annual mandatory educational session about extremity restraint safety. Which of the following actions should the nurse manager plan to take?

Send an email to each non-adherent employee that includes a link to upcoming educational sessions. Email provides a simple yet efficient way for the nurse manager to inform non-adherent employees about options for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the email facilitates adherence by helping each employee identify an upcoming session that coordinates with his/her work schedule.

A nurse is reviewing laboratory results for a client who is at 12 weeks gestation. Which of the following findings should the nurse report to the provider?

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

An experienced nurse is serving as a mentor to a newly licensed nurse. Which of the following actions should the mentor take?

Serve as a guide and teacher for the newly licensed nurse in an established relationship. A mentor establishes a nurturing relationship with a newly licensed nurse and is willing to invest time and resources to help this person develop as a nurse and an individual.

A nurse manager notes several recent conflicts among nurses on different shifts. Which of the following strategies should the nurse manager use to resolve these conflicts?

Set up a series of meetings for all staff members to attend to discuss issues. Through this approach, the nurse manager is using the conflict-resolution strategy of collaboration by encouraging all staff members associated with the conflict to communicate and work together to devise and implement win-win solutions.

A nurse is admitting a client who has active gastrointestinal bleeding. Which of the following tasks is appropriate for the nurse to delegate to an assistive personnel (AP)?

Show the client how to use the nurse call light. The AP can show the client how to use the nurse call light, as this task does not require an assessment of the client first.

A nurse working in a mental health facility is preparing to discharge a client who has schizophrenia and requires assistance with housing. Which of the following referrals should the nurse recommend to the provider?

Social worker. The nurse should identify that a social worker assists clients with issues such as finances, day-to-day concerns, and suitable housing options.

A nurse in a provider's office observes a newly licensed nurse taking a client's health history while in the waiting area. Which of the following actions should the nurse take?

Speak to the nurse immediately in private. The newly licensed nurse is violating client confidentiality and federal HIPAA regulations. Personal health information could be overheard by others in the waiting room. The nurse must immediately stop this behavior and speak to the newly licensed nurse in private to protect the privacy and confidentiality of the client.

A nurse is part of a facility committee charged with developing and implementing new documentation forms. The nurse should recognize which of the following factors as a potential restraining force for implementing this change?

Staff members' resistance to learning new forms of documentation. Restraining forces impede change. Staff members' resistance to learning a new documentation system can be a restraining force. As a result, the committee must develop a plan for implementation that recognizes this threat.

A nurse is walking with a client who falls after the facility-issued walker loses a wheel. Which of the following actions should the nurse take regarding the completed incident report?

Submit the variance report to the risk manager. Incident reports are confidential documents used by the institution to improve client care. Filing an incident report does not supersede the need for documenting the assessment in the client's medical record and notifying the provider. Once completed, the variance form should be submitted to the institution's risk manager.

A nurse is caring for several clients who require diagnostic testing and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse direct the AP to perform first?

Take an arterial blood gas specimen to the laboratory. Arterial blood gas specimens are placed on ice and must be transported to the laboratory immediately to prevent degradation of the sample. Since this task needs to be done within a specified timeframe, it is the first task the AP should perform.

A charge nurse is observing a group of newly licensed nurses. Which of the following actions should the charge nurse report to the nurse manager as a violation of HIPAA?

Talking about clients with other nurses in the cafeteria. The nurse should not discuss information about clients—including their personal concerns, diagnoses, and treatments—with anyone who is not directly involved in the client's care. Doing so is a violation of HIPAA regulations. Nurses should take special care not to compromise this right by discussing client care in such places as elevators, restaurants, or other areas that are accessible to the public in which the discussion might be overheard.

A charge nurse is planning a performance appraisal for a newly hired assistive personnel (AP). Which of the following factors should the charge nurse take into consideration when planning a performance appraisal interview for the AP?

The AP should have a copy of the performance standards before the appraisal interview. The AP should have a copy of the performance standards prior to the interview in order to indicate what his/her performance is being measured against.

A nurse is teaching a group of unit nurses about the Health Insurance Portability and Accountability Act (HIPAA). Which of the following pieces of information should the nurse include in the teaching?

The Security Rule provides a uniform level of security to protect client records. The security rule provides a uniform level of protection of clients' records, which includes maintaining the confidentiality, integrity, and availability of the client's records.

A nurse is providing teaching about a living will for a client who has end-stage breast cancer. Which of the following pieces of information should the nurse include in the teaching?

The client has the right to change the living will at any time. A living will is one component of advance directives. This legal document that expresses the client's wishes regarding health care decisions in the event the client becomes incapacitated or is unable to make decisions. The client has the right to change or revoke the living will at any time.

A nurse is caring for an adult client who has pancreatitis. The client tells the nurse, "I've decided that I want to go home. I don't want any more treatment." The nurse should recognize that which of the following legal principles applies to the client?

The client has the right to make the decision to leave the hospital. Even though the nurse and the provider may think it inadvisable, a client who is not involuntarily admitted has the right to decide to leave at any time. Nurses and providers have a responsibility to ensure that the client is aware of potential risks and injury that can result from leaving and refusing further treatment before discharging the client against medical advice. The nurse should fully document this information and the client's response in the medical record.

A nurse is evaluating a client's understanding of discharge teaching about dressing changes. Which of the following actions by the client indicates an understanding of the teaching?

The client restates the information in her own words. When the client restates the information in her own words, the nurse can assess the client's understanding of the teaching. The nurse can observe and listen for gaps in understanding and proceed to correct items as necessary.

A nurse is caring for a client who is dying and unable to make decisions for himself. The client's adult children disagree about his code status. Which of the following sources should the nurse depend on for decisions regarding the client's end-of-life care?

The client's health care proxy. If the client cannot speak for himself, the nurse should follow the directions of the client's health care proxy, as this is the person the client chose to make decisions under these circumstances.

A home health care nurse is conducting a home hazard assessment. For which of the following findings should the nurse intervene?

The client's household lamps have 40-watt light bulbs installed. The nurse needs to intervene for low-wattage light bulbs. Inadequate lighting increases the risk of falls and presents a safety hazard for the client.

A nurse is working with an assistive personnel (AP) in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks?

The degree of supervision that the AP will require to complete the task. Successful delegation involves assigning the right task to the right person under the right circumstances. The person who will perform the task must be given adequate direction and specification regarding the amount of supervision that will be provided. The right communication of expectations and the right feedback about performance must also be supplied.

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following situations should the nurse complete a variance report?

The discovery that a preoperative client has received and eaten breakfast. This situation represents a variation from the standard of care. A change in the client's plan of care is necessary because the surgical procedure will need to be delayed. The nurse should complete a variance report for this situation.

A charge nurse is providing teaching to a new staff nurse about the management of a team consisting of a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following pieces of information should the charge nurse include in the teaching?

The nurse should be familiar with the task she plans to delegate. The nurse should be familiar with the task she plans to delegate so she can define the task as well as the expectation of its completed status, monitor the performance of the task, and provide feedback regarding the performance.

A nurse is teaching a newly licensed nurse about the informed consent process for a client who is scheduled for a surgical procedure. Which of the following pieces of information should the nurse include in the teaching?

The person who will perform the procedure is responsible for obtaining informed consent. The person performing the procedure is legally responsible for obtaining informed consent. Informed consent includes telling the client about the risks and benefits of the procedure, alternative treatments available, and possible outcomes if the procedure is not performed.

A nurse on a medical-surgical unit is delegating tasks to nursing team members. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Transferring a client who is postoperative from a bed to a chair. Tasks that a nurse should delegate to an AP include transfers, ambulation, vital-sign measurement, and other simple procedures that do not involve assessment or teaching.

A nurse is ambulating a client who has an IV with an infusion pump. After the nurse returns the client to his room and plugs in the infusion pump, the client reports a slight tingling in his hand. Which of the following actions should the nurse take?

Turn off the pump. The pump must be turned off immediately to protect the client and the nurse from the risk of electrical injury and fire. The nurse should consider any electrical equipment that shows a sign of malfunction to be unsafe and place it out of service until it can be checked by the facility's maintenance department.

A nurse is following standard policy and procedure for reporting a client who has a communicable disease. Which of the following infections should the nurse plan to report to the CDC?

Vancomycin-resistant Staphylococcus aureus. The nurse should follow policy and procedure for reporting a client who has vancomycin-resistant S. aureus (a communicable disease) to the CDC.

A nurse in a community health clinic is planning an in-service staff training session on nationally notifiable infectious conditions. Which of the following conditions should the nurse include in the teaching?

Varicella. The nurse should identify that varicella is a nationally notifiable infectious condition.

A nurse manager notes that a full-time nurse has been absent from work 6 times over the last 6 weeks. Using a nonpunitive approach, which of the following actions should the nurse manager take?

Verbally remind the employee about the facility's employment standards. Verbal admonishment is the first step in the disciplinary process for this type of infraction. The employee might not know or remember the existing standard, and a verbal reminder may be sufficient to change the employee's behavior.

A nurse is reviewing informed consent with a client who is scheduled for a cardiac catheterization. Which of the following is the responsibility of the nurse?

Verifying the client's understanding of the procedure being performed. The nurse must verify that the client understands and can describe the procedure being performed.

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

Win-yield. A win-yield approach involves both parties no longer trying to resolve the conflict. Instead of taking the initiative to end the conflict, they agree to honor whatever the nurse manager decides.

Based on recommendations following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff nurses on the unit is resistant to the change, and the nurse manager notes that this nurse does not deliver care according to the new policy. Which of the following actions should the nurse manager take?

Encourage the staff nurse to verbalize reasons for resisting the change. The nurse manager should realize that if the nurses who must implement the change are not invested in the change process, resistance is likely. This is especially problematic when the change is unplanned or imposed by outside forces. The resistant staff nurse has likely rejected the change due to prior habits, fear of the unknown, and lack of time to learn something new. A meeting between the nurse manager and the staff nurse will provide an open forum for the staff nurse to verbalize the reasons for reluctance in adopting the new policy.

A charge nurse in an emergency department is making assignments for an assistive personnel (AP) during a shift with unexpected staff absences. Which of the following assignments should the charge give to a float AP from the medical-surgical unit?

Escorting clients from the emergency department to other areas of the facility for tests. Clients in the emergency department often require transport to other departments. Typically, transporting stable clients is a task that may be delegated to an AP, and escorting clients is likely a normal part of the AP's regular routine.

A nurse suspects that a coworker is under the influence of alcohol. Which of the following behaviors in the workplace are consistent with substance use disorder? (Select all that apply.)

Extended lunch periods and breaks is correct. Extended lunch periods and breaks might indicate that the individual is ingesting alcohol in a remote location. Calling in sick frequently on Mondays or Fridays is correct. Calling in sick frequently on Mondays or Fridays might indicate that the individual is binge drinking on weekends and is too ill to come to work. Frustration with work assignments is incorrect. Frustration with work assignments is a common workplace behavior but this behavior does not indicate substance use disorder. Decrease in concern about personal appearance and grooming is correct. Decrease in concern about personal appearance and grooming is a sign of substance use disorder. Excessive use of cologne or mouthwash is correct. Excessive use of cologne or mouthwash is a sign of substance use disorder and indicates that the individual is attempting to cover up the smell of alcohol.

A nurse is assisting a provider with an amniotomy on a client who is in labor. Which of the following is the priority nursing assessment following the procedure?

Fetal heart rate. The greatest risk to this client is an injury from umbilical cord prolapse following artificial rupture of the membranes; therefore, the nurse should monitor the fetal heart rate for bradycardia, which can indicate an increased risk of umbilical cord prolapse.

A nurse is preparing to transfer an older adult client to a long-term care facility. To promote continuity of care, which of the following actions should the nurse plan to take?

Give a written summary of the client's nursing plan of care to the long-term care facility. A written summary of the client's nursing plan of care will convey his needs to the nurses who will be working with him in the long-term care facility.

A nurse is creating a plan of care for a client who adheres to Kosher dietary laws. Which of the following food selections should the nurse recommend?

Grilled salmon. The nurse should recommend grilled salmon for a client who observes Kosher dietary laws. Grilled salmon is a fish with fins and scales, which can be consumed. Seafood with shells, such as lobster or crab, is prohibited.

A nurse manager is implementing a team nursing approach on his unit, hiring licensed practical nurses (LPNs) and assistive personnel (AP) as additional staff. Which of the following actions should the nurse manager take to facilitate acceptance of this change?

Introduce the new approach and facilitate the development of a task force to plan implementation. This appropriate approach involves the staff in the planning and will give them a feeling of control over their practice and enhance acceptance of the change.

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

Laissez-faire. This nurse manager is a laissez-faire leader, providing little support or guidance. The leader's activity is minimal and contributes to reduced staff efficiency.

A nurse is caring for a client who is on bed rest and states, "I would prefer not to have all of the side rails on my bed raised." After assessing the client is safe without the four side rails raised, which of the following interventions should the nurse implement?

Leave the side rails down and document this decision as per the client's request. Raising all four side rails can be considered a form of restraint if they restrict the client's ability to get in and out of bed. This client is on bed rest and does not require that level of mobility; however, if the client expresses a wish for the rails to be down, the client's level of consciousness is not impaired, and there is no other specific safety hazard posed by lowering the side rails, the client's request should be respected.

A nurse is documenting data about a client at a computer terminal in the nurses' station when he has to leave the area to assist another client. Which of the following actions should the nurse take?

Log off the computer before leaving the nurses' station. To ensure no one else has access to the client's protected health information, the nurse should log off the computer terminal and turn off the monitor.

A charge nurse is making daily assignments for a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measuring vital signs. According to the National Council of State Boards of Nursing, delegation is the transferring of authority to perform a selected nursing task in a certain situation to a competent individual. Examples of tasks a nurse can delegate to an AP are measuring and documenting vital signs, performing postmortem care, and measuring and documenting intake and output.

A charge nurse overhears a unit nurse informing other unit nurses that the charge nurse is giving preferential treatment to the unit nurses on the night shift. Which of the following approaches by the charge nurse reflects an assertive response to resolve this conflict?

Meeting one-on-one with the unit nurse to discuss these concerns. The charge nurse should schedule a time to speak privately with the unit nurse about the situation. Assertive behavior involves discussing a situation directly with the person involved.

A charge nurse on a medical-surgical unit is making client assignments for the oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)?

A client who has a prescription for irrigation of an indwelling urinary catheter. It is within the scope of practice of an LPN to irrigate an indwelling urinary catheter when prescribed by a provider.

A charge nurse is making shift assignments for a team that includes RNs, licensed practical nurses (LPNs), and assistive personnel. Which of the following clients should the nurse assign to an LPN?

A client who has emphysema and pneumonia and is receiving oxygen. This client requires routine care, medication administration, and data collection. This is an appropriate client to assign to an LPN.

A nurse is preparing to teach the health care team about the concept of critical pathways. Which of the following statements about the purpose of a critical pathway should the nurse plan to include?

"A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline." A critical pathway outlines the actions that members of the health care team must complete in a timely manner to achieve desired client outcomes and an appropriate length of stay for the particular diagnosis.

A nurse is talking with a family member who is unhappy about the care his mother is receiving. Which of the following responses should nurse make?

"Can you give me a specific example of care that caused dissatisfaction?" Requesting an example of a specific event can allow the nurse to view the family member's comments objectively and address his concerns.

A nurse is caring for a client who received a sedative-hypnotic medication at bedtime. The client gets out of bed and falls, sustaining a laceration that requires suturing. Which of the following statements should be included as part of the nurse's documentation in the client's chart?

"Client found sitting on floor with 3 cm laceration above left eyebrow. Oriented to name only. Provider notified." This statement is appropriate to include in the documentation. It presents objective facts and assessments related to this event. The nurse should also include vital signs, further assessments, the name of the provider notified, treatments or procedures that were done per the provider's prescription, and the client's response.

A nurse is caring for a client who asks if the client in the next room is in pain because she cries out frequently. Which of the following statements should the nurse make?

"Does the crying out bother you?" This therapeutic response focuses on the client's feelings rather than on confidential information concerning the client in the next room. It summarizes the client's question and poses an open-ended, relevant query for the client to expand on if desired.

A nurse is caring for a male client who is scheduled for a procedure. The client's son asks the nurse what medication is being given to the client. Which of the following responses should the nurse provide?

"I am sorry, but you'll need to ask your father for that information." The nurse must keep the client's personal health information confidential. It is up to the client to share confidential information with his son.

A nurse manager believes that a nurse is taking breaks that are too frequent and lengthy. Which assertive statement should the charge nurse use to initiate a discussion of the issue?

"I understand you are allowed to take scheduled breaks during each shift, but you are taking more than the number allocated. Let's set a time when we can discuss this behavior." Assertive communication uses "I" statements that describe the person's observations and feelings. It allows the person being confronted to respond to the issue with his/her own perceptions and feelings instead of feeling verbally assaulted. Subsequently, a verbal discourse can follow that allows an open discussion of the issue.

A nurse is caring for a child who has sustained extensive head injuries. The provider has diagnosed brain death. Which of the following statements should the nurse use to begin a conversation about the option of organ and tissue donation with the child's parents?

"I want to give you some information about an option that you have regarding donating your child's organs to others who are in need." This is an appropriate statement to begin the discussion. It clearly conveys the nurse's intention to give the family factual information and does not make any emotionally-laden statements.

A nurse in a mental health clinic is interviewing a client who has a history of substance use disorder. The client reports his experiences from a previous voluntary hospitalization. Which of the following reported experiences by the client constitutes assault?

"I was threatened with a shot when I refused to take an oral medication that I knew would make me groggy." Threatening to medicate clients against their wishes is assault. The tort of assault occurs when a person puts another in fear of nonconsensual contact.

A nurse is teaching a newly licensed nurse about advanced directives. Which of the following statements by the newly licensed nurse indicates an understanding of this teaching?

"I will assess the client's understanding of life-sustaining measures." The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures in order to make informed decisions in advance directives.

A nurse from a facility's float pool receives an assignment to float on a nursing unit. The float nurse tells the charge nurse that she has never worked on this unit before. How should the charge nurse respond?

"I will assign you to work with a registered nurse on the unit who is experienced and will act as a resource for you." Providing the float nurse with a co-assigned resource person is appropriate. This resource is part of a float pool, not just a nurse floating from another unit, and it is likely that she will be assigned to this unit in the future. The charge nurse can facilitate her orientation to the unit by providing a resource person who is skilled in the care provided to clients on the unit.

A nurse is teaching a group of newly licensed nurse managers about the principle of justice. Which of the following statements by a nurse manager indicates an understanding of this teaching?

"I will compose staff schedules so that each person works two holidays a year." Justice means treating everyone fairly. By scheduling each person to work two holidays per year, the nurse manager is requiring staff members to work an equal share of holidays.

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

(A) A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol (B) A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine (C) An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics The nurse should place clients who can be quickly and safely discharged on the potential discharge list. Children who have asthma can be managed at home once the acute phase of illness has resolved. Because the preschool client's manifestations are responsive to the prescribed medication, this child can be safely discharged home with appropriate discharge teaching and follow-up care planning. External fixation devices are worn for weeks to months; they are often managed at home once the device is placed and the client has learned how to care for the immobilized limb. This school-age client's pain is responsive to oral codeine. Prior to discharge, the client might need instructions on ambulation and weight-bearing, as prescribed. Long-term antibiotic therapy is typically completed in the home following PICC line placement. A visiting nurse can assist this adolescent client with home care management. The client's developmental delay has no bearing on whether the client is safe to discharge.

A charge nurse is planning a department in-service training session about radioactive implants for a group of staff nurses. Which of the following points should the charge nurse include in the presentation? (Select all that apply.)

(A) Clients should be placed in a private room (C) Staff members should wear a dosimeter badge when caring for the client. (D) Clients should be on bedrest Clients should be placed in a private room to avoid exposing other clients to radiation from the implant. The nurse should follow the principles of time, distance, and shielding when working with a client who is receiving internal radiation therapy. Health care providers should wear a dosimeter badge while caring for a client who has a radioactive implant. This badge measures and records a staff member's amount of exposure to radiation. Clients who have a radioactive implant should remain on bed rest while the implant is in place to prevent dislodgement.

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

(A) Collecting a stool specimen (C) Measuring oral intake (D) Providing postmortem care The nurse should delegate collecting a stool specimen, measuring oral intake, and providing postmortem care to the AP. These tasks do not require assessment, analysis, or teaching and are within the range of function for an AP.

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

(A) Completing one task before beginning another task (C) Taking time to plan care at the beginning of the shift (E) Mentally visualizing a procedure prior to gathering equipment Completing one task before beginning another task, planning care at the beginning of the shift, and mentally visualizing a procedure prior to gathering equipment are effective time-management strategies for the newly licensed nurse. Daily planning is important for managing and prioritizing tasks.

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

(B) Cleanse the wound with tap water. (E) Discard soiled bandages in a moisture-proof bag. Tap water or 0.9% sodium chloride should be used to cleanse the wound. Soiled bandages and gloves should be placed in double-bagged, moisture-proof bags and not in the regular trash. This prevents the spread of contamination to other family members within the household.

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

(B) Measuring a client's intake and output (D) Providing postmortem care to a client Measuring the intake and output of a client and providing postmortem care are within the range of function for an AP.

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

(B) Notifying the provider when a client has questions about the procedure (C) Helping a client make a list of questions to ask the provider (D) Clarifying the dosage of a medication prescribed for a client who has impaired liver function (E) Carrying out the end-of-life wishes outlined in the living will of an older adult client who has end-stage renal disease As a client advocate, the nurse should make sure clients have all their questions answered and possess the information needed to make an informed decision. Clarifying the dosage of a medication prescribed for a client who impaired liver function can prevent medication toxicity and demonstrates client advocacy. Carrying out the end-of-life wishes of a client who has end-stage renal disease demonstrates client advocacy.

A nurse on a medical-surgical unit is planning the care of assigned clients. Which of the following clients should the nurse attend to first?

A client who has a cast newly applied on the forearm and reports tingling of the fingers. When using the airway, breathing, circulation (ABC) approach to client care, the nurse should first assess the client who has a newly applied cast on the forearm and reports tingling of the fingers. Tingling, numbness, pallor, paresthesia, and pain are clinical manifestations associated with compartment syndrome, a serious development in which increased tissue pressure in a confined anatomical space reduces blood flow, leading to ischemia, dysfunction, and eventual necrosis. The nurse should report this finding to the provider immediately.

A charge nurse on a pediatric unit is delegating tasks to an assistive personnel (AP) who is pregnant and reports that she is unsure of her immune status. Which of the following clients should the charge nurse assign to the AP?

A 2-year-old child who has impetigo contagiosa (impetigo). This is a safe assignment. If the AP practices universal precautions, there is no risk of contracting impetigo. Impetigo is a superficial skin infection caused by either Staphylococcus or Streptococcus.

A charge nurse receives a call from the nursing supervisor about an explosion at a local factory and an urgent need for facility beds for newly admitted clients. Which of the following clients should the nurse recommend for discharge?

A 44-year-old client with asthma who was admitted for carpal tunnel surgery. A client who is admitted for carpal tunnel surgery is stable and having an elective procedure. Therefore, the nurse should recommend this client for discharge.

A nurse in an emergency department is caring for 4 clients. Which of the following findings requires the nurse to act as a mandatory reporter?

A child who was left unsupervised for several hours at home and is being treated for a fractured leg. This child exhibits findings of neglect and endangerment. The nurse is a mandatory reporter for any client situation in which children or older adult clients are being abused or neglected.

A nurse is preparing to care for a group of clients after receiving change-of-shift reports. Which of the following clients should the nurse assess first?

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

A nurse is planning care for several clients. Which of the following clients should the nurse refer to a case manager?

A client who has neurological deficits following a stroke. The nurse should refer this client to the case manager for care. A client who had a stroke will likely require long-term treatment. A client who has ongoing needs for care or rehabilitation should receive care that is directed by a case manager due to the complexity and cost of the client's needs.

A nurse is teaching a group of newly licensed nurses about violations of client rights. Which of the following examples of a violation of client rights should the nurse include in the teaching?

A client who has schizophrenia is placed in the seclusion room of the psychiatric unit for making frequent outbursts of obscenities directed at nurses of the opposite sex. Seclusion is a restraint that should be used when a client is demonstrating violent or self-destructive behavior that jeopardizes the safety of self or others. This client does not meet the criteria for seclusion.

A nurse is selecting clients for discharge following an environmental disaster. Which of the following clients should the nurse select?

A client who is 1 day postoperative following an inguinal hernia repair. The nurse should select the client who had an inguinal hernia repair for discharge because this client is stable.

A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)?

A client who is disoriented and awaiting a transfer to a long-term care facility. A client who is disoriented will need observation and reality orientation, which is within the LPN's scope of practice. The client's condition can also be categorized as stable since discharge to a long-term care facility is scheduled.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients should the nurse attend to first?

A client who is receiving cephalexin and reports dyspnea. The greatest risk to this client is an injury from dyspnea due to an allergic reaction from the antibiotic. The client is at risk of anaphylactic shock with a compromised airway; therefore, the nurse should first discontinue cephalexin and notify the provider immediately. Emergency equipment should be placed in the client's room in case the client goes into anaphylactic shock.

A nurse is prioritizing care for a group of clients. The nurse should plan to attend to which of the following clients first?

A client who requires endotracheal suctioning. When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should attend to a client who requires endotracheal suctioning first. Without this intervention, mucus and secretions could accumulate and block the client's airway.

A nurse manager is observing the staff members working on her unit. Which of the following actions should the nurse manager recognize as an example of paternalism?

A nurse practitioner withholding information from a client who is dying to avoid causing the client distress. Paternalism is a type of relationship between clients and health care providers in which the health care providers believe they know what is best for the clients. In this example, the nurse practitioner withholds information so as not to cause the client distress. This practitioner is making the decision for the client and denying the client the right to be informed.

A charge nurse is conducting an in-service training session on ethics to a group of newly licensed nurses. Which of the following situations should the charge nurse include as an example of the ethical principle of veracity?

A nurse truthfully answers the client's questions about upcoming chemotherapy. A nurse who truthfully answers the client's questions about treatment, such as chemotherapy, is demonstrating the ethical principle of veracity. Veracity refers to telling the truth and being straightforward and clear with clients about the treatment being delivered.

A school bus crash in the community creates an urgent need for pediatric hospital beds. Which of the following clients should the nurse manager recommend for discharge?

A preschooler admitted with tonsillitis who has been receiving oral antibiotics for 24 hr. This preschooler admitted with tonsillitis is stable and is receiving oral antibiotics; therefore, the preschooler can be discharged with antibiotics to be continued at home.

A nurse manager is participating in a root cause analysis following a sentinel event on the unit. Which of the following statements defines the purpose of a root cause analysis?

A root cause analysis investigates deviations from standards of care surrounding the event. A root cause analysis is a function of quality improvement seeking to determine what factors led to a deviation from established standards of care that resulted in errors in client care.

A nurse is caring for a client who is in the bathroom. The nurse hears a loud thud and, after opening the bathroom door, finds the client on the floor. What is the priority nursing action?

Determine the client's level of consciousness. Checking the client's level of consciousness is the first action the nurse should take after a fall. This client might have had a vasovagal response while defecating, resulting in a temporary loss of consciousness that does not require CPR.

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process?

Instruct clients who are able to ambulate to leave. Clients who are able to ambulate should leave first in an evacuation process, as this quickly reduces the number of clients who require evacuation assistance.

A nurse manager is planning staff development activities for the unit's new unlicensed assistive personnel (UAP). Which of the following activities should the nurse manager perform first?

Determine the learning needs of the UAPs. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, he/she must first collect adequate data. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision; therefore, the nurse manager should first determine the learning needs of the UAPs.

Using high-quality monitoring tools, a facility committee identifies that clients who have congestive heart failure have an average length of stay of 5 days instead of the established standard of 3 days. Which step should the nurse implement next in the quality-improvement process?

Determine which actions can be instituted to address this problem. Further analysis of data will identify factors that contribute to longer lengths of stay. Identifying actions to shorten the clients' lengths of stay is the next step in the process.

A nurse is caring for a client who is undergoing a repair of an abdominal aortic aneurysm. After the surgery and immediate postoperative recovery, the nurse should expect which of the following team members to coordinate the client's ongoing and specific needs for care?

Case manager. The case manager's role is to plan and coordinate resources and services to help meet the client's needs over the continuum of care.

A nurse is caring for 4 clients who are scheduled for diagnostic tests. For which of the following tests should the nurse obtain written consent from the client?

Cerebral arteriogram. A cerebral arteriogram is considered invasive because it involves injecting contrast material into an artery to study the cerebral circulation. Written consent is required.

After entering a client's room, a nurse notices the client has fallen on the bathroom floor. Which of the following actions should the nurse perform first?

Check the client for injuries. The greatest risk to this client is an injury from falling on the floor; therefore, the first action the nurse should take is to look for skin tears, cuts, or bruises and to obtain the client's vital signs.

A nurse is reviewing the medication administration record for a client and notes that the nurse from the previous shift gave double the dose of antihypertensive medication prescribed to the client. Which of the following actions should the nurse take first?

Check the client's condition. The greatest risk to this client is an injury from low blood pressure due to a double dose of antihypertensive medication. Therefore, the first action the nurse should take is to check the client's condition and obtain the client's vital signs, including blood pressure.

A nurse is participating in an ethics committee meeting about a client who has a history of alcohol use disorder and needs a liver transplant. Which of the following actions should the committee take first?

Collect information related to the issue. According to evidence-based practice, the committee should take the first step in ethical decision-making by identifying the ethical issue and problem. This step includes asking questions to define the issue and the complexities of the situation.

A health care facility's leadership team is implementing a new computerized charting system. When preparing for the implementation date, which of the following actions should the nurse manager take first?

Collect the staff members' input about planning and implementing the change. The nurse manager should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he/she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse manager should first assess the situation by collecting the staff members' input and collaborating about implementing the change smoothly and efficiently.

A nurse discovers that the wrong medication was given to a confused client who answered to the name the nurse stated when entering the room. The provider is notified and reports that the medication the client received will not cause any harm. Which of the following actions should the nurse take?

Complete an incident report documenting the occurrence. An incident report should be initiated whenever an error is made involving a client, even if no injury occurred. Incident reports are also used for statistical purposes in determining the types of incidents that occur. These reports may help administrators recognize if a particular type of incident is occurring at an undesired frequency to determine if intervention is needed.

A charge nurse finds an increased incidence of health-care-associated infections (HAIs) on a long-term care unit. Which priority action should the charge nurse take to address the problem?

Conduct a chart review to gather data about clients who developed HAIs. The charge nurse should first conduct a chart review or audit in order to gather data about the clients who developed infections. This information will provide the charge nurse with potential indicators or factors that resulted in the increased incidence of HAIs.

A nurse is planning to perform a negotiation to manage a conflict between himself and another staff member. Which of the following actions should the nurse plan to take?

Create a solution in which all parties are satisfied. The goal of negotiation is to create a win-win situation in which all parties are satisfied with the results. Both parties involved in the conflict should be willing to make concessions.

A nurse is caring for a postoperative client who has an Hgb of 8.0 g/dL. The nurse delegates the administration of a unit of packed RBCs to a nurse floating from a psychiatric unit who is unfamiliar with blood administration. Which of the following actions should the float nurse take?

Decline to hang the blood. The nurse has a legal duty to decline tasks that cannot be performed safely and competently. A float nurse from a psychiatric unit would not be familiar with the current policy regarding blood administration, and this nurse has limited experience with this procedure. Therefore, the task should be assigned to another nurse.

A nurse is planning care for a group of clients. Which of the following actions should the nurse plan to take?

Delegate the administration of an intermittent tube feeding to a licensed practical nurse (LPN). Administering a tube feeding is within the scope of practice for an LPN.

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

Democratic. The democratic manager encourages the staff to participate in decision-making, communicates effectively, offers constructive criticism, and believes the best of people.

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

Democratic. This is an example of democratic leadership. A democratic leader guides staff toward an objective and shares responsibility with the staff. This is the ideal type of leadership in this situation because a great amount of creativity can occur, and many strategies can be developed.

A nurse manager observes a nurse entering the room of a client who is on contact precautions without donning personal protective equipment (PPE). Which of the following is the priority action for the nurse manager to take?

Have the nurse exit the room and don proper PPE. The nurse manager should apply the safety and risk-reduction priority-setting framework when intervening with the nurse. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse manager should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse manager should first ensure the safety of the staff and clients by having the nurse exit the room and don proper PPE before re-entering the room.

A nurse is preparing an IM injection for a client who is preoperative when another client suddenly calls for assistance. The nurse asks another nurse to give the injection since an assistive personnel is waiting to take the client to surgery. Which of the following actions should the second nurse take?

Help the client requesting assistance so the first nurse can give the prepared injection. The second nurse should help the other client so the first nurse can give the injection. The nurse who has prepared the injection is the only one who can safely identify what is in the syringe and be responsible for correctly administering the medication.

A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following client injuries receives treatment first?

Hemothorax. The nurse should apply the survival potential priority-setting framework in mass casualty situations, when resources are scarce and resources must be allocated to save the greatest number of lives. While it could seem that the client who is most at risk should receive priority care, this client is the lowest priority. The nurse should assign the highest priority to the client with injuries that are severe who has the potential to survive with treatment. Therefore, the nurse should recommend that the client who has a hemothorax receives treatment first. A hemothorax is life-threatening, but with chest-tube insertion and stabilization, the client is likely to survive.

A nurse in an acute care facility is implementing the facility's disaster plan following a flood in the community. Which of the following actions should the nurse take?

Identify stable clients in the ICU to transfer to the medical-surgical unit. The nurse should identify clients to transfer to the medical-surgical unit to increase the availability of ICU beds for clients from the external disaster who are critically ill.

A nurse is having difficulty completing care and documentation without staying past the end of the shift. The nurse manager suggests focusing on time-management skills. Which of the following strategies should the nurse plan to use?

Identify tasks in order of their priority. Prioritizing is an important time-management strategy. The nurse should prioritize each client's needs and tasks and attend to the highest priority client first.

A nurse is completing an incident report after administering an incorrect dose of medication to a client, even though the client experienced no ill effects from the error. What is the purpose of completing the incident report?

Identifying situations that contribute to the occurrence of medication errors. The purpose of completing incident reports is to identify factors that contribute to the occurrence of the problem. This is one aspect of quality-improvement efforts in health care facilities.

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

Planning. The nurse should write expected outcomes as part of the planning phase of the nursing process. During planning, the nurse establishes goals and outcomes for the client and selects the interventions that will help achieve those goals and outcomes. Planning also involves setting care priorities.

A nurse is caring for a client who has recently been prescribed lithium carbonate. Which of the following assessment findings is the priority for this client?

Poor motor coordination. When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is poor motor coordination, which is an advanced manifestation of lithium carbonate toxicity. The nurse should hold the client's medication and notify the provider.

While participating in a continuous quality-improvement program, a nurse is reviewing medical records to determine the time of first postoperative ambulation of clients who had abdominal surgery. In which type of quality audit is the nurse participating?

Process. A process audit measures the interventions used to facilitate expected and desired outcomes for clients. Early ambulation is essential for the prevention of postoperative complications.

A nurse manager is orientating newly licensed nurses to a facility and is emphasizing the importance of practicing within standards of care. To which of the following legal concepts is the nurse manager referring?

Professional negligence. Standards of care establish safe nursing practices. Professional negligence occurs when a nurse is acting in a manner that a reasonable and prudent nurse would not, resulting in unsafe care. Professional negligence constitutes malpractice.

A charge nurse is teaching a group of unit nurses about alternative restraints for clients who are confused and wandering. Which of the following pieces of information should the nurse include in the teaching?

Provide the client with a rocking chair. The nurse should advise providing the client with a rocking chair to expend some of the client's energy through rocking rather than walking, which leads to wandering.

A nurse is discussing palliative care with the family of a client who is terminally ill. Which of the following should the nurse include as the purpose of palliative care?

Providing comfort measures. Palliative care is an approach to care that promotes comfort for a client who has a terminal diagnosis and is not receiving aggressive therapy. Palliative care focuses on managing manifestations of the disease, not on curing the disease.

A nurse is tracking the outcomes of clients on the unit who have received postoperative pain management. This activity demonstrates which of the following competencies of the Quality and Safety Education for Nurses (QSEN) initiative?

Quality improvement. This QSEN competency involves using data to track outcomes with the goal of devising processes to improve clients' outcomes.

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)?

Recording urinary output after emptying the indwelling urinary catheter. Emptying an indwelling urinary catheter and recording intake and output are within the scope of practice for an AP. These tasks are routine and have predictable outcomes; therefore, the nurse may delegate this task to an AP.

A nurse is caring for a client who is a local public official. A newspaper reporter repeatedly phones the unit seeking information and states, "The public has a right to know the health status of elected officials." Which of the following actions should the nurse take?

Refer all media inquiries to the nursing supervisor. The HIPAA Privacy Rule prohibits disclosing client information to individuals who are not involved in care without the client's express consent. The reporter should be told that, due to confidentiality issues, no information can be given about any client. The nurse should refer the reporter to the nursing supervisor.

A nurse is preparing a client for discharge. The client states, "My partner hurts me. I don't want to go home." Which of the following actions should the nurse take?

Refer the client to social services for assistance in seeking safe housing. MY ANSWER It is the duty of the nurse to assist the client in finding safe housing and protection from the offending partner.