Leadership practice 2019 A

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as a priority? A. Child has red fissures at the corners of their mouth B. Child has several small bruises on both legs C. Child sleeps for 13 H hour each night D. Child is not regularly attending school

A. Child has red fissures at the corners of the mouth. Use Maslow's hierarchy of needs, this can indicate a vitamin B deficiency which is a physiological need.

A nurse is planning discharge care for a client who had a stroke and now has left side weakness. Which of the following interventions should the nurse include in the plan of care? A. Request purchase from DME B. Advise patient to install grab bars in bathroom at home C. Encourage client to allow HHA to perform ADLs discourages independence D. Contact Hospice to provide follow-up care

B. Advise patient to install grab bars in bathroom at home. Reduces risk of falls.

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? A. The age of client B. Availability of community support groups C. Length of clients stay D. Type of insurance the client carries

C. The length of clients stay. The client's clinical pathway is a standardized approach to assist the nurse to provide cost-effective client care and shorten the length of stay.

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? A. Podiatrist B. Social worker C. Paramedical technologist D. Occupational therapist

D. Occupational therapist. The nurse should recommend a referral to a OT when a client has difficulty with ADLs, such as buttoning clothing. OT can assist the client with exercises to help the client complete these tasks.

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

Determine the client intake and output. 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.

A nurse is preparing to give 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.

A nurse is caring for a client who is comatose. The client has a living will 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 clients request with the family. 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.

A nurse on a MedSurg unit has arrive late to work multiple times over the past several weeks. Identify the sequence the nurse manager should follow when disciplining the employee

Schedule a meeting with the nurse Provide a written reprimand Temporarily remove the nurse from scheduled shifts Terminate the nurses employment

An assistive personnel tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent. Which of the following responses should the charge nurse make? A. I delegate tasks to personnel based on their job descriptions B. Everyone working here has to care for clients who are in continent C. Let's talk about organizing the workflow so you care for fewer of these clients D. Why do you not want to care for clients who are in continent.?

A. 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.

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? Select all that apply -role model a positive approach to changes -redirect the conversation with staff make negative comments about the changes -encourage staff members who support the changes to discuss the issue with resistant staff -suggest that resistant staff members transfer to different unit -reprimand staff members who are resistant to the changes

- Role model a positive approach to changes. - Encourage staff members who support the changes to discuss the issue with resistant staff.

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

A client who has a femur fracture in reports feeling short of breath.

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 client should be assigned to the medical nurse?

A client you had a right above the knee amputation 24 hours 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 hours, so the residual limb does not require special care at this time.

A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? A. A nurse photocopying their assigned clients diagnostic test results B. AP documents a client VS on clients paper-based graph record C. Unit secretary faxing clients lab results to the provider D. RN stays with client who is reading the medical records that were requested

A. Nurse photocopying their assigned clients diagnostic test results

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.

A nurse received 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

A nurse is caring for a client who is terminally ill and receiving nutritional support. The clients 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. 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.

A nurse is receiving report from the AP assigned to the nurse's group of clients. Which of the following statements from the EAP indicates the client the nurse should assess first A nurse is receiving report from the AP assigned to the nurses group of clients. Which of the following statements from the AP indicates the client the nurse should assess first? A. Client who had ABD surgery three days ago and reporting feeling constipated B. Client who had hip surgery reports pain 4/10 C. Client indwelling urinary catheter removed eight hours ago reports inability to void D. Client who is scheduled for discharge today states they are ready to sign their paper

C. Client who had indwelling urinary catheter removed eight hours ago reports 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 UTI.

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 clients bedside. This allows the client to be involved with their care. The nurse should avoid giving report in public areas, such as in the hallway.

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. This response is appropriate because it indicates the nurse understand that the client's report is the best indicator of pain and is not making any assumptions.

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. Regardless of the type of health care facility or admission status, clients maintain the right to refuse medications.

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.

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? A. Notify charge nurse of clients request to transfer B. Assured client that their concern has been shared with the staff C. Tell client that future calls will be answered in timely manner D. Ask client to verbalize their expectations

D. Ask 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.

A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?

Discuss the clients feelings about the procedure.

Two nurses on a unit each 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. This allows the nurses to collaborate, which creates a higher probability that the nurses will reach a successful resolution.

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

Fidelity Fidelity: actions are taken to display loyalty and keep a promise made to the client. Beneficence: actions are taken to "do good" and promote goodness and kindness. Utility: 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: actions are taken to seek fairness, where all clients are treated equally regardless of sex, sexual orientation, religion, ethnicity, disease, or social standing.

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. Other indications can include frequent errors, mood swings, inability to focus, and excessive wasting of controlled substances.

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 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.

A nurse is caring for a 19-year-old client who has just been informed that her 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.

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 the 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 clients.

A nurse manager needs to address increased rate of client medication 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. The nurse manager is using penalties to promote behavior change; this is characteristic of authoritarian leadership.

A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty (TKA) and speaks a different language than the nurse. Which of the following inter-professional team members should the nurse include in the discussion?

Interpreter

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

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.

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. The first action the nurse manager should take when using the nursing proces is to assess. The nurse should conduct a chart audit to gain important information about the factors responsible for the increased incidences of infection.

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 action should the newly licensed nurse take?

Pick up the first sterile glove by grasping the folded cuff edge

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.

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

Platelets 100,000. A client who has a platelet count of 100,000/mm^3 is unstable because this value is below the expected reference range of 150,000 to 400,000/mm^3, which places the client at risk for bleeding; therefore, the nurse should visit this client first.

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

Provide enteral feeding to a client who has Crohn's disease.

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.

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

Raise the footplates of the wheelchair before transferring the patient.

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. The nurse should verify that the client has given informed consent prior to receiving moderate sedation because this involve anesthesia.

A nurse asks a newly hired AP 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 skill competency checklist. A review of the AP's checklist should validate that they have demonstrated the ability to safely perform the procedure.

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

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

The client who has a sucking chest wound.

A nurse is caring for a client who is 3 days postoperative 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 clients level of consciousness. The nurse should include objective data regarding the client's current consciousness status in the verbal report.

I charge nurse is observing a nurse perform a sterile dressing change. Which of the following actions should the charge nurse identify as demonstrating sterile technique?

The nurse places the sterile package with the top flap opening away from the body.

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

The right to be treated with respect and dignity The right to refuse their medications The right to leave regardless of provider recommendations The right to be fully informed of their health conditions

A nurse is caring for a client who is hospitalized and has expressive aphasia. The clients family 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. 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.

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 N 95 respirator mask when in the clients room.

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 statement should the nurse make?

Your case manager will coordinate the resources you will need.

A nurse walks into the nurses station and sees several staff members looking at the electronic medical record EMR record of a celebrity client on another unit. Which of the following actions should the nurse take first? A. Remind the staff members that this is a breach of confidentiality B. Discuss the issue with the nurse manager C. Request that administrative restriction be placed on the clients record access D. Prepare a memo for facility ethics committee

A. Remind the staff members that this is a breach of confidentiality. 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.

A nurse on a MedSurg unit is caring for four clients. The nurse should recognize that which of the following clients is the priority? A. A client who is scheduled for a tubal ligation in two hours and is crying B. A client who has PVD and absent pulse in right foot C. A client who has T1DMN needs first dressing change for ulcer D. A client who has MR essay and axillary temp of 38°C

B. A client who has peripheral vascular disease and absent pulse in right foot. When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is an absent pulse, which indicates no blood flow to the extremity.

Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an AP? A. Take vital signs every two hours for the client you had a choleycystectomy in room 6122 B. Check the UO at 11 o'clock for John Doe and report it to me immediately C. Report to me if the chest tube drainage is excessive for Jane doe in room 2438 D. Please notify me of any clients who is vital signs or blood glucose levels are significant

B. Check the Urinary Output at 1100 for John Doe and report it to me immediately 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 coat collection, and the expectation for communicating the findings back to the nurse

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? A. Assess clients incision Q8 hours for first 48 hours B. Inform AP of clients weight bearing status C. Instruct client to cross legs at ankles when sitting D. Teach clients partner to assist the client to flex the hip at least 120° each hour

B. Inform the AP of the clients weight bearing status. 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.

A case manager is planning interprofessional conference for a client who is three days postop following ORIF of right hip. Which of the following concerns is the priority for discussion at the conference? A. Client does not have transportation for DC home B. Client refuses to attend PT sessions C. Clients home health nurse has not completed the home assessment D. Client describes feelings of depression after family visits

B. 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

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? A. Set target dates for completion B. Identify areas of support C. Determine goals and objectives D. Implement recommended strategies

C. 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.

A nurse is caring for a client who is recovering from a stroke. The provider recommends extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following action should the nurse take? A. Informed the client of consequences of decreased cerebral circulation B. Initiate mental health consult to determine why client refuses surgery C. Discussed clients concerns about having the surgery D. Provide client with information on additional treatment options

C. Discuss clients concerns about having the surgery. The nurse should ask the client relevant questions to determine their concerns regarding having the surgery. By asking relevant, open-ended questions, the nurse can help the client clarify their thoughts and feelings about the surgery. The nurse can then relay these concerns to the provider for further discussion if needed.

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? A. Write a memorandum emphasizing the importance of attending staff meetings B. Appoint a task force to promote attendance at the meetings C. Explore the reasons that staff are not attending the meetings D. Reduce the number of meetings the staff are required to attend

C. Explore the reasons the staff are not attending the meetings. According 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.

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? A. Documents client tasks at end of shift B. Gather supplies as needed while completing activity C. Groups tasks that are in same location D. Skips breaks throughout the day to complete work on time

C. Groups tasks that are in same location. 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.

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? A. Assigned to clients who have had a stem cell transplant to the same room B. Obtain rectal temp Q4 hours C. Where an N 95 respirator mask while caring for these clients D. Place clients in positive pressure airflow rooms

D. Place clients and positive pressure airflow rooms. The patient requires protective equipment precautions following a stem cell transplant in a private, positive pressure airflow room. The room air is filtered through a HEPA filter and the air flow rate is set at more than 12 error exchanges per hour