Management Quiz #8

Logroll the client with three staff members when turning the client side to side.

The client is 8 hours postoperative spinal surgery. Which priority intervention should the nurse implement?

"Can you tell me what you don't like about your doctor's care?"

The client tells the nurse, "I do not like my doctor and I want another doctor." Which statement is the nurse's best response?

The client who is 1 week postoperative for L3-L4 laminectomy who is complaining of numbness and tingling of the feet.

The nurse is working in an orthopedic unit. Which client should the nurse assess first?

The nurse requests not to be floated to the NICU.

The nurse on the surgical unit is being sent to the neonatal intensive care unit (NICU) to work because the unit is short staffed. The nurse has never worked in the NICU. Which response by the nurse supports the ethical principle of nonmalfeasance?

The client who has full-thickness burns who needs to be medicated before being taken to whirlpool.

The nurse received the a.m. shift report on the following clients. Which client should the nurse assess first?

"The counselor will assist you with job placement, training, or further education."

The nurse tells the client, "I am going to refer you to the vocational counselor." The client asks the nurse, "Why are you making this referral?" Which statement is the nurse's best response?

The UAP requests the client to turn to the side.

The nurse tells the unlicensed assistive personnel (UAP) to assist the client who is 1 day postoperative spinal surgery with a.m. care. Which action by the UAP warrants immediate intervention?

Have the clients and visitors remain in the hallway with the doors closed.

The overhead page has issued a Code Black, indicating a tornado in the area. Which intervention should the charge nurse implement?

Interrupt the conversation and tell the UAP to go to the nurse's station.

The primary nurse overhears the unlicensed assistive personnel (UAP) telling a family member of a client, "One of the clients will be going to prison because that person was charged with vehicular manslaughter. Two people in the motor vehicle accident died." Which action should the primary nurse implement first?

Praise the UAP for positioning the client prone.

The unlicensed assistive personnel (UAP) on the rehabilitation unit is placing the client with a left above-the-knee amputation in the prone position. Which action should the nurse implement?

Assess the client's residual limb dressing.

The unlicensed assistive personnel (UAP) tells the nurse the client with a right above-the-knee amputation has a large amount of bright red blood on the right leg residual limb. Which action should the nurse implement?

"What time do you prefer bathing and do you take a tub bath or a shower?"

The nurse is assessing the client's daily schedule and habits. Which question is most appropriate for the nurse to ask the client?

Katz Index of ADLs grade G.

The nurse is assessing the functional ability of a client using the Katz Index of Activities of Daily Living (ADLs). Which assessment grade would require the nurse to delegate feeding, bathing, and toileting to the unlicensed assistive personnel (UAP)?

Instruct her son not to move the left leg.

The nurse is at a local playground and her 10-year-old son falls and complains of his left ankle and foot hurting. Which intervention should the nurse implement first the scene of the accident?

Ask the woman if she has an EpiPen.

The nurse is at the local mall and a young woman starts having shortness of breath, has hives on her face and arms, and is complaining of itching. Which intervention should the nurse implement first?

Ask the UAP to cleanse the client's dentures and place in the container.

The nurse is caring for a client diagnosed with a full-thickness burns over the right lower extremity. Which task should the nurse delegate to the UAP?

Explain the Americans with Disabilities Act (ADA) to the client.

The client with bilateral amputations tells the nurse, "I was told I can't go back to my job because they don't have handicap accessible bathrooms or ramps." Which action by the nurse is most helpful to the client?

"I will contact the case manager and have her talk to you as soon as possible."

The client's husband is frustrated and tells the nurse, "Everyone is telling me something different as to when my wife is going to be bale to go home. I don't know whom to believe." Which statement is the rehabilitation nurse's best response?

Initiate the hospital policy for unacceptable behavior.

The clinical manager has verbally warned a female staff nurse about being late to work on two previous occasions. The nurse was 35 minutes late for today's shift. Which action should the charge nurse take?

Weigh the client once a week and document the weight on the patient record. Stay with the client twice a week while the significant other (SO) goes out to run errands. Take and record the client's vital signs.

The home health (HH) nurse has arranged for a home health aide (HHA) to assist a 79-year-old client diagnosed with Alzheimer's disease. Which interventions should the nurse delegate to the HHA? Select all that apply.

1 tablet

The home health (HH) nurse is arranging for the significant other (SO) of an elderly client diagnosed with heart failure to administer the routine diuretic medication furosemide (Lasix). The medication is to be administered 20 mg on Monday/Wednesday/Friday and 40 mg on Sunday/Tuesday/Thursday/Saturday. The prescription is for 40 mg scored tablets. How many tables should the nurse teach the SO to administer on Sundays?

1. The 67-year-old client diagnosed with emphysema who called to report that the sputum is rusty color this morning. 2. The 29-year-old client diagnosed with spinal cord injury (SCI) post-motor vehicle accident (MVA) who needs a dressing changed on a Stage IV pressure area. 3. The 72-year-old client diagnosed with atrial fibrillation who needs a prothrombin time performed and called to the HCP. 4. The 56-year-old client diagnosed with breast cancer who needs an injection of filgrastim (Neupogen) subcutaneously. 5. The 80-year-old client diagnosed with Alzheimer's disease who is confused and wandering around the house.

The home health (HH) nurse is planning to make rounds for the day. List the order the clients should be seen by priority.

"The case manager is a nurse who will coordinate the rehabilitation team and keep you informed."

The male client is placed in a double hip spica cast for 3 months. The client's wife tells the nurse, "My husband said we are supposed to talk to his case manager. What is a case manager?" Which statement is the nurse's best response?

Notify the clinical manager of the sexual harassment.

The male nurse who has been told by the female nurse on previous occasions not to talk to her about her body says, "You really look hot in that scrubs suit. You have a great-looking body." Which action should the female nurse take next?

Place the abductor pillow between the client's legs.

The nurse and the unlicensed assistive personnel (UAP) are caring for a 74-year-old client who is 3 days postoperative right total hip replacement (THR). Which nursing task should be delegated to the UAP?

Assist with bowel training by escorting the client to the bathroom.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a rehabilitation unit. Which nursing task is most appropriate for the nurse to delegate to the UAP?

Acupuncture Guided imagery Music therapy

The nurse is discussing alternative medication (CAM) with a client on the rehabilitation unit. Which therapies should the nurse discuss with the client? Select all that apply.

The antihistamine to the client with urticaria and pruritus.

The nurse is preparing to administer morning (a.m.) medications to the following clients. Which medication should the nurse administer first?

Put a gait belt around the client's waist.

The nurse is preparing to ambulate the client with full-thickness burns on the lower extremities down the hall. Which priority intervention should the nurse implement?

Check to determine whether the client has received pain medication.

The nurse is preparing to change a dressing on an 82-year-old client with a Stage III pressure ulcer. Which intervention should the nurse implement first?

The client reports redness and itching on the hands.

The nurse is triaging phone calls in a dermatological clinic. Which client warrants the nurse making an appointment immediately?

Ensure the client is correctly placed in the lift prior to moving.

The nurse is using an electric patient "Hoyer" lift to transfer the client from the bed to a stretcher. Which priority intervention should the nurse implement?

The primary nurse asks another nurse to administer an injection she prepared.

Which action by the female primary nurse would warrant immediate intervention by the charge nurse on the rehabilitation unit?

The nurse leaves the computer screen open at the nurse's station.

Which action by the primary nurse requires immediate intervention by the charge nurse?

The UAP tied the confused client to a chair with a sheet.

Which action by the unlicensed assistive personnel (UAP) warrants immediate intervention by the nurse?

The client diagnosed with an open reduction and external fixation (ORIF) of the right hip who has a hemoglobin and hematocrit (H&H) of 8/24.

Which client should the charge nurse on the rehabilitation unit assess first after receiving the a.m. shit report?

Administer oxygen via nasal cannula.

Which intervention should the nurse implement first for the client with a fractured femur who is suspected of having a fat embolism?

Turn the client every 2 hours or more often.

Which priority intervention should the nurse implement to help prevent pressure ulcers in the client who is on strict bed rest?

Encourage the UAP to attend the multidisciplinary team meeting.

Which task should the rehabilitation nurse delegate to the unlicensed assistive personnel (UAP)?

Ask the client whether he has any sexual concerns he needs to discuss.

The 28-year-old male client who sustained traumatic bilateral amputations secondary to a motor vehicle accident (MVA) is being discharged home to live with his wife and 3-year-old son. Which priority psychosocial intervention should the rehabilitation nurse discuss with the client?

The client with fractured tibia who has deep, unrelenting pain.

The charge nurse on the acute care rehabilitation unit is making assignments for the shift. Which client should the charge nurse assign to the most experienced nurse?

The RN who transferred to the rehabilitation unit from the medical unit.

The charge nurse on the busy 36-bed rehabilitation unit must send one staff member to the emergency department (ED). Which staff member is the most appropriate person to send?

Tell the UAP to elevate client's residual limb above the heart.

The charge nurse on the rehabilitation unit is assigning/delegating tasks to the unlicensed assistive personnel (UAP) and licensed practical nurse (LPN). Which task is most appropriate for the nurse to delegate/assign?

Have the LPN call the HCP to obtain an order for a diet change.

The charge nurse on the rehabilitation unit is making assignments for the day shift. Which assignment would be most appropriate for the licensed practical nurse (LPN)?

The client on antibiotic therapy who has a serum potassium level of 3.3 mEq/L.

The charge nurse received laboratory data on the following clients. Which client warrants immediate intervention by the charge nurse?

Request the LPN to apply antifungal cream to the client with tinea pedis.

The charge nurse, a licensed practical nurse (LPN), and two unlicensed assistive personnel (UAPs) are caring for clients. Which action is most appropriate for the charge nurse to assign/delegate?

Determine whether the client has any injuries.

The client ambulation down the orthopedic hallway unassisted fell to the floor. Which action should the nurse implement first?

The physical therapist.

The client diagnosed with a fractured right ankle needs to be instructed on crutch walking. Which member of the multidisciplinary team should address this problem?

Prepare the client for a biopsy of the abnormal skin growth.

The client has an area on the skin the dermatologist thinks may be basal cell carcinoma. Which intervention will the nurse implement to confirm the diagnosis?

Apply warm moist heat to the affected area.

The client has cellulitis on the right lower leg. Which intervention should the nurse implement?

"I can see you must feel helpless; I am here to listen."

The client in a motor vehicle accident (MVA) is in critical condition with a pelvic fracture, flail chest, bilateral arm fractures, and a left hip fracture. The client tells the nurse, "I just want to die. I can't feed myself or clean myself." Which statement is the nurse's best response?

"Let me check and see if you can receive pain medication before therapy."

The client in the rehabilitation unit tells the nurse, "I will not go to physical therapy again because it hurts so much when I do the exercises." Which statement supports the nurse's role as a client advocate?

Assess for paresthesia and paralysis.

The client is 1 week postoperative for right below-the-knee amputation secondary to arterial occlusive disease. The nurse is unable to assess a pedal pulse in the left foot. Which intervention should the nurse implement first?

Insert two large-bore intravenous access routes.

The client is admitted to the emergency department (ED) with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement?

Instruct the client to notify his or her healthcare provider immediately.

The client tells the nurse, "I have a mole on my back which is darker and getting larger." Which intervention should the nurse implement first?

Explain that the nurse cannot witness this document.

The client tells the primary nurse, "I just finished completing my living will and I need you to witness my signature." Which action should the nurse implement?

"The physical therapist will help you with exercises to improve your muscle strength."

The client who was admitted to the rehabilitation uint because of a debilitative state asks the nurse, "Why do I have to go to physical therapy every day?" Which statement is the nurse's best response?

Encourage the client to push the residual limb against a pillow. Use warm soap and water to remove the crusts secondary to impetigo. Ensure all staff members wear gloves when caring for client.

The client with a right below-the-knee amputation who also has impetigo is admitted to a rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.

Place the client on cardiac telemetry.

The client with an electrical burn is brought to the emergency department (ED). The entrance would is on the right hand and the exit wound is on the left foot. which intervention should the nurse implement first?

"The state rehabilitation commission will help retrain you."

The client with an upper extremity amputation tells the nurse, "I do everything with my right hand and now it is gone. I have no idea what I am going to do after I get discharged. How will I support my family? I will need to get a new job." Which statement is the nurse's best response?

Refer the client to the home health nurse.

The elderly wife of a client with a total hip replacement who is being discharged home tells the nurse, "I am really worried about taking my husband home. I don't know how I will be able to take care of him." Which intervention is most appropriate for the nurse?

The UAP is assisting the client who weighs 181 kg to the bedside commode.

The nurse in the rehabilitation unit is caring for clients along with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention?

1. Apply a gait's belt around the client's waist. 2. Ensure the client places the cane in the strong hand. 3. Request the client to move the cane forward. 4. Move the weaker leg one step forward. 5. Move the stronger leg one step forward.

The nurse is assisting the client to use a cane when ambulating. Rank in order of performance the interventions the nurse would take.

Honor the client's request and answer any questions the wife has on the phone.

The rehabilitation nurse enters the client's room and the client is talking not he phone. The client asks the nurse to talk to his wife because she has some questions. Which action should the nurse take?

Administer an antibiotic ointment four times a day. Instruct the parents to keep the child at home until lesions crust over. Tell the parents to use separate towels for the child.

The school nurse notes the child has impetigo. Which interventions should the nurse implement? Select all that apply.

The UAP had the client elevate the legs prior to putting on the stockings.

The unlicensed assistive personnel (UAP) is applying elastic compression stockings to the client. Which action by the UAP indicates to the nurse the UAP understands the correct procedure for applying the elastic compression stockings?

1. Place the wheelchair at an angle on the client's strong side. 2. Lock the wheelchair brakes and secure the chair position. 3. Assist the client to stand and put strong hand on the wheelchair armrest. 4. Keep the client's weight forward and pivot the client. 5. Lock the wheelchair brakes and secure the chair position.

The unlicensed assistive personnel (UAP) is transferring the client from the bed to the chair. Which interventions should the nurse ensure the UAP implements during this procedure? Rank in order of priority.