NU 302 Management of Care Question Set 1

When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be:

"You seem upset this morning."

A mental health nurse receives the following phone messages. Which client with the nurse call back first?

A client with a history of illicit drug use who stated "My family would be happier if I was not around."

A staff nurse on a busy pediatric unit would like to function effectively in the role of a leader. Which action would the nurse employ to be a leader?

Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

anxiety

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant?

completion of range of motion on limbs restrained

A school-age child reveals to the nurse that a parent has been abusive. What constitutes a breach of the child's right to confidentiality?

telling the child in the next room, who also suffered abuse, so the two children can talk to each other

A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority?

risk for injury

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?

Notify the supervisor and provide care until another nurse can be assigned to the client.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

A hospitalized client fell on the floor and sustained a small laceration on the hand that requires stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. Which issue should be resolved before proceeding with suturing?

bupivacaine with epinephrine used as the local anesthetic.

The nurse is a member of a team that is planning a client-centered, community-based approach to care of clients with chronic obstructive pulmonary disease. In which areas should the team focus on improving quality of care and delivery? Select all that apply.

A. the community B. Clinical information systems C. delivery system design

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first?

a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally

An adolescent with pneumonia shares fears of having contracted human immunodeficiency virus (HIV). The adolescent wants to be tested but does not want parental involvement. What should the nurse say?

"The healthcare provider will run the test confidentially." EXPLANATION: Federal laws state that adolescents may be tested for sexually transmitted diseases without their parents' permission. The rules of confidentiality apply to this adolescent. The adolescent doesn't have to speak with anyone before the test. HIV can be contracted at any age, even during infancy and childhood. Asking why the client thinks HIV is possible may exhibit therapeutic communication, but it does not address the client's concern.

A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation?

Inform the other nurse that the viewed screen resulted in a breach of confidentiality. EXPLANATION: Nurses must protect the privacy of all client information, and this includes information on an electronic medical record. The computer screen at the nurses' station should not be in view of anyone other than the person accessing the record. The other answers are incorrect because they breach client confidentiality.

The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do?

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller.

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction?

"I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."

A client who has been prescribed chemotherapy wants to take herbal treatments instead. What should the nurse tell the client?

"Tell me about your concerns with chemotherapy."

The recipient of a donated organ asks the nurse, "What did the donor die from?" Which response by the nurse is most appropriate?

"The transplant coordinator can give you information about the donor's medical history." EXPLANATION: Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers; however, medical history, such as history or hepatitis or HIV infection, is permitted. The transplant coordinator is the liaison for information regarding the donor.

A palliative care nurse is caring for a client with end stage pancreatic cancer who is reporting severe pain. The healthcare provider orders morphine sulfate 4mg IV stat followed by morphine sulfate 2mg IV q 1h prn pain. The drug available in a multidose ampule of 2mg/mL. How many mL does the nurse administer for the initial dose? Record your answer as a whole number.

2

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is most likely the occurrence that is disturbing to this client?

A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner.

After completing the nursing assessment for a client and family entering the palliative care program. Which are appropriate nursing goals at this time? Select all that apply.

A. Achieve a dignified and respectful death. B. Maximize the client's quality of life. C. Provide comfort during the dying process. D. Offer support for the client's family.

The home health nurse is visiting an 80-year-old client diagnosed with Alzheimer's dementia. During the visit, the nurse notes bruising on the client's face and upper arms in various shades of healing. The client is unable to communicate effectively because of the disease progression. What is the nurse's responsibility in this situation? Select all that apply.

A. Bring up the suspected physical abuse with a trusted authority figure. B. Report the suspicion to the local Adult Protective Services Agency within 24 hours. C. Monitor the situation during the subsequent home visits. EXPLANATION: A nurse is a mandated reporter of abuse. If the nurse suspects abuse, they must report it to the local Adult Protective Services Agency. You can protect seniors by bringing up the issue of abuse with a trusted authority member. While monitoring alone is not sufficient, the nurse would continue to monitor the situation. Trying to convince a client with dementia to report the abuse themselves is inappropriate. Doing nothing is not an appropriate nursing action.

The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply.

A. Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. B. Client's dressing is intact with scant amount of serous drainage. C. Client ambulated to end of hallway.

Which activities should the nurse encourage the unlicensed assistive personnel (UAP) to assist with in the care of postoperative clients? Select all that apply.

A. Empty and measure indwelling urinary catheter collection bags. B. Reposition clients for pain relief. C. Tell the nurse if clients report they are having pain.

The hospital accreditation visitors are present on the nursing unit. What nursing actions will protect client privacy during the visit? Select all that apply.

A. Keep the client's curtains closed when providing direct care. B. Log off the computer screen when not in use. C. Secure client's medical records in a locked cabinet.

The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.

A. Obtain vital signs for a client admitted yesterday. B. Obtain intake and outputs on a client experiencing heart failure. EXPLANATION: Taking vital signs and obtaining intake and output are tasks that can be delegated to UAP. Assessing pedal pulses and administering medications or oxygen are skills that require nursing judgment.

A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply.

A. type of surgery B. current vital signs C. amount of blood loss D. fluids infusing including rate and type of fluid EXPLANATION: Transfer reports must include information about the client's surgery, all current treatments and medications, vital signs, including pain level, fluid status including blood loss, and current IV infusions. It is not necessary to identify the surgeons who were present during the surgery or report the name of the insurance provider.

A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tube is accidentally pulled out of the chest wall. What should the nurse do first?

Apply an occlusive dressing such as petroleum jelly gauze.

The nurse manager is preparing to meet with several registered nurses (RNs) in the department to address practice issues. Which behavior by an RN will the nurse manager address as a violation of the RN's "duty to care"?

declined assignment to care for a client with dementia who was incontinent of stool

Which guidelines define and regulate what the nurse may and may not do as a professional?

nurse practice act

Which client will the community health nurse visit first?

the client with type 1 diabetes mellitus with acute visual changes

A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as

the principles that determine whether an act is right or wrong

A coworker asks another nurse if a client received their pathology report. The coworker is not directly involved in the care of the client. How should the nurse respond? Select all that apply.

A. "You need to review the hospital policy related to client privacy." B. "I'm sorry, but I'm not at liberty to give you that information." C. "Information can only be shared if you're involved in the client's care." EXPLANATION: The nurse should tell the coworker that information about the client cannot be shared due to health privacy laws. In addition, client information can only be shared with those who are involved in the immediate care of the client. Hospital policies usually address such issues, and this information is covered during orientation and annually as an update.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply.

A. Provide explanations and support to the client. B. Attend to the client's physical needs. C. Report any signs of abuse to appropriate agencies. EXPLANATION: Physical needs are met first, and then the determination of the existence of abuse will wait until the client's physical condition is stable. It is the duty of the nurse to tell the client the truth about what will happen and to support the client should not be turned away for telling a lie. A nurse should not tell the client that a secret will be held, as the client or another person may be put in danger if the abuser is not stopped.

A nurse is named as a defendant in a pediatric client case. What are guidelines for the nurse to follow prior to the trial? Select all that apply.

A. Use polite language while answering questions. B. Be prepared to answer questions about the case during the trial.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply.

A. Use the hospital code for HIV when documenting care. B. Ask all family members, except the client's significant other, to wait outside when she's educating the client.

Which action performed by a nurse will increase the risk of liability? Select all that apply.

A. assisting a client on ordered bed rest to walk to the toilet B. asking unlicensed assistive personnel to assess a client's wound C. providing information to a caller about a client's diagnosis and treatment

A nurse who is working with a nursing assistant is making care assignments for the shift. Which task would be appropriate for the nurse to delegate to the nursing assistant? Select all that apply.

A. checking vital signs B. documenting oral intake on the I&O flow sheet C. assisting with a bed bath for a client who had surgery yesterday

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.

A. to ensure efficient and accurate communication B. to prevent medication errors C. to ensure client safety

A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply.

A. type of surgery B. current vital signs C. amount of blood loss D. fluids infusing including rate and type of fluid

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms

A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today but had to cancel the appointment when the child became ill. Which action should the nurse take?

Arrange for the pump to be refilled in the hospital.

A nurse is monitoring a client who developed facial edema after receiving a medication by tablet. What should the nurse do next?

Assess for shortness of breath.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error. How should the nurse correct the error made in documentation?

Cross out the incorrect statement with a single line.

A client with cancer of the stomach tells the nurse, "I cannot bear the pain anymore. Please give me some poison to free myself from this agonizing pain." The nurse faces a value conflict. Which is true in such a condition?

Human need may affect the values conflict.

Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception. Which is a benefit of this method of documentation?

It provides quick access to abnormal findings.

A client reports chronic lower back pain and fatigue, and has been seen by multiple care providers without relief of symptoms. The client insists that something is terribly wrong. Which action should the nurse take first?

Obtain a thorough health assessment to rule out physical illnesses.

Which measure should a home healthcare nurse implement to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

An adult client who is alert and oriented requires surgery. The client cannot read. Which nursing interventions is the best?

Read the consent form to the client and have the client verbalize understanding.

A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP?

Reassign the UAP to a client requiring basic tasks that the UAP has mastered.

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which actions should the nurse prioritize when attempting to establish an effective relationship with the client?

Recognize and address the client's anxiety.

A client has been prescribed a brand-name medication for a newly diagnosed condition. The client tells the nurse, "I do not know what to do. I cannot afford that medication. I may just have to keep suffering with these symptoms." What should the nurse do to best assist this client?

Recommend the client ask the health care provider if the client can take the generic brand of the medication instead of the brand-name medication.

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client?

Refer the client to her health care provider for evaluation and treatment of the pain.

A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching?

Report bile-colored drainage from any incision.

A female client who is hospitalized for an eating disorder weighs 15 lb (6.8 kg) less than the ideal body weight. Which goal is a priority for this client?

The client gains 1 lb (0.5 kg) per week.

The nurse is planning staffing assignments for a group of clients. Which client is most appropriate for the nurse to assign to a nurse who normally works on the maternity unit?

a client who had an open appendectomy yesterday

The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most appropriate for this client?

a darkened private room as close to the nurses' station as possible

A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan?

discussing collaborative goals and involving the client in identifying and prioritizing important interventions

The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child's allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents?

identifying ways to reduce the child's exposure to the allergens

The nurse is assigned a client newly diagnosed with type 2 diabetes. Which tasks should the nurse delegate to a unlicensed assistive personnel (UAP)?

reminding the client to check the glucose level before each meal

A nurse is caring for several clients on an oncology unit. Which client should the nurse see first?

client with a white blood cell count of 2000 µL

A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN?

Perform a straight catheterization for protein analysis.

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client?

registered nurse (RN) with 2 years of experience

A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained?

"I wonder if there is any other way to prevent these bad rhythms."

A client is participating in a cardiac research study in which the client's physician is directly involved. Which statement indicates a need for additional teaching about the client's rights as a research study participant?

"I'll have to find a new physician if I don't complete this study."

A client of a homecare nurse gives the nurse an envelope with a small amount of money in it, stating, "It's a tip for the good care you give me." Which statement would be the most appropriate response from the nurse?

"I'm grateful that you're satisfied with the care you're receiving, but I can't accept any form of gift."

A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which would be the most appropriate response by the nurse to the surgeon?

"It is your responsibility to obtain informed consent from the client." EXPLANATION: It is the surgeon's responsibility to obtain the informed consent after explaining the procedure to the client, including the risks, benefits, and alternatives. The other options are incorrect because they place the responsibility for obtaining informed consent on another person.

A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. The client requests that their evaluation and counseling records be e-mailed to the client's Human Resources representative. How should the nurse respond?

"It's best not to e-mail your personal records because doing so might put your privacy at risk."

A nurse is caring for a 9-year-old child who is scheduled for surgery. The parents ask the nurse not to tell the child about the surgery until leaving for the operating room. What response best demonstrates the nurse's role in supporting the child's rights?

"It's important to tell your child about the surgery to allow time for any questions to be answered." EXPLANATION: Advance awareness of the surgery and its significance offers a school-age child time to develop coping strategies and formulate questions. Failure to inform the child about the surgery ahead of time may result in fear or mistrust of healthcare workers or the healthcare system. Children are not able to sign consent. The legal obligation of informing the child of surgery is not seen as the best action to support the child's rights.

A client is scheduled for a right lower lobectomy for lung cancer. During the admission assessment, the client asks for information about a living will and advance directive. The nurse knows that the client understands teaching about the living will and advanced directive when the client says

"The advance directive allows me to state my healthcare wishes while I'm still able to do so."

A client with mild dementia related to end-stage acquired immunodeficiency syndrome is preparing for discharge. The client has decided against further curative treatment and wishes to return home. Before discharge, the client develops ocular cytomegalovirus (CMV). The physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's partner feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the partner's question reflecting client advocacy?

"The implant won't cure the virus, but it may help preserve your partner's vision. Not being able to see you or the surroundings may worsen your partner's dementia and make caring for your partner at home more difficult."

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management?

"We can discipline the ED staff for not getting the clients to the ICU fast enough."

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alfa as alternatives to a blood transfusion. Which response by the nurse causes the supervising nurse to plan a review of professional and ethical standards?

"You should take the unit of blood. It will help you feel better."

An alert and oriented client refuses chemotherapy. The client's family believes that the client should receive it. Which is the nurse's best response to the client?

"You understand that this decision is ultimately yours to make."

The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used.

1. Verify the client has signed an informed consent. 2. Position the client in a side-lying position. 3. Clean the skin with an antiseptic solution. 4. Apply ice to the biopsy site. EXPLANATION: First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then, the nurse should clean the skin site and surrounding area with an antiseptic solution before the health care provider (HCP) numbs the site and collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action?

Discuss the unit's policy with the charge nurse.

The student nurse is learning about pain. The nurse educator asks the student, "Pain is best described as what?" What is the student's most appropriate response? Select all that apply.

A. unpleasant B. subjective EXPLANATION: The International Association for the Study of Pain defines pain as "a subjective, unpleasant, sensory, and emotional experience associated with actual or potential tissue damage."

The registered nurse (RN) is supervising for the evening shift at a long-term care facility. The RN is working with 3 certified nursing assistants (CNA) and a licensed practical/vocational nurse (LPN/VN). Which aspect of care is most appropriately delegated to the LPN/VN?

Administering a client's tube feeding

A nurse is considering employment at a hospital where nurses belong to a collective bargaining unit. How will the potential employee benefit from the collective bargaining unit? Select all that apply.

A. negotiation for wages B. negotiation for improved work environment C. organization of social activities EXPLANATION: Nurses who belong to a collective bargaining unit will have negotiation for wages and improved work environments. Collective bargaining units may sponsor social activities for members. The collective bargaining unit does not help with preferred work hours or childcare. The membership for a collective bargaining unit is not free; dues for membership are required.

A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply.

A. Cover the body with a sheet. B. Transport the body to the morgue. EXPLANATION: The UAP can cover the body and transport it to the morgue. Deaths by gunshot wound are considered reportable deaths. All evidence in a reportable death, including tubes and IV lines, should remain intact until the coroner has been contacted. The health care provider (HCP) should be the one to notify the family. The nurse should be the one to notify the chaplain.

The nurse has withdrawn a narcotic medication from the dispenser at a skilled nursing facility. The medication is ordered as needed. When the nurse enters the client's room, the client refuses the medication while the family is visiting. How will the nurse proceed with the correct procedure? Select all that apply.

A. Destroy the narcotic tablet immediately with a second nurse. B. Offer the option to have the narcotic when the client feels it is needed. EXPLANATION: The nurse will destroy the narcotic tablet immediately with a second nurse and offer the option to have the narcotic when the client feels it is needed to respect refusal and dispose of narcotic safely. The client has the right to refuse the narcotic. The narcotics must be stored safely and should not be relabeled by the nurse or kept for later administration.

During a home visit to an older adult with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply.

A. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. B. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. C. Promote relaxation before bedtime with a warm bath or relaxing music.

A nurse is caring for a client on life support in the cardiac care unit. The client's family, which is strongly religious, is unable to unanimously decide to remove life support. What should the nurse do? Select all that apply.

A. Notify the hospital's ethics committee of the ethical dilemma. B. Request pastoral services to assist the family in this decision. C. Initiate family discussions around what the client would have wanted. EXPLANATION: Ethics committees are a valuable resource for reviewing difficult cases and helping ensure a careful and unbiased decision when advocating for the client. Since the family is religious, it is appropriate to request pastoral services or ask them if they would like their spiritual advisor called. Therapeutic communication with the family about their loved one's wishes is appropriate and often helpful. It is not therapeutic to ask a family to leave their loved one to pray or to pressure the family for a unified decision. It is inappropriate to provide pamphlets on funeral services to a family struggling with end-of-life decisions.

The standards of practice in the Nurse Practice Act describe duties of nursing practice according to the nursing process. What are examples of the implementation standard of a registered nurse? Select all that apply.

A. delegating vital signs B. applying a warm compress for back pain C. administering medication for leg pain EXPLANATION: The implementation duties include delegating vital signs, applying a warm compress, and administering medication. The nurse completing an assessment is the assessment phase and the encouragement of ambulation is the part of health promotion.

A nurse receives a new order from the healthcare provider to keep the client nothing by mouth (NPO). Which member(s) of the healthcare team need to be alerted to the new NPO order? Select all that apply.

A. dietary personnel B. unlicensed assistive personnel C. respiratory therapist EXPLANATION: The direct care providers like an unlicensed assistive personnel and the respiratory therapist need to be aware of the new order. The dietary department also needs to be aware for dietary tray management. While a wound nurse and case manager may see a client, both need to assess the client status before providing care such as fluids.

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistive personnel (UAP)? Select all that apply.

A. providing skin care following bowel movements B. maintaining intake and output records C. obtaining the client's weight

A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, "This is turning me into an old woman before my time." What is the best response by the nurse?

Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems.

A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She does not have transportation. How can the nurse help this client be compliant with her care?

Ask the clinic case manager to speak with the client.

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer?

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain, and administer prescribed analgesics.

The nurse is unable to find the health record (chart) for a client who has arrived for a clinic visit. Which is the best action by the nurse?

Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?

Collaborate with the physician to make a referral to social services. EXPLANATION: Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her partner does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security.

The nurse is caring for a client who wishes to stop medical treatment. Which action by the nurse best demonstrates the role of the nurse as a client advocate?

Communicate the client's wishes to the healthcare provider.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next?

Check the computerized care plan to determine what test was scheduled.

The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, what should the nurse do?

Consult the drug guide provided by the clinical agency.

A nurse is caring for a client who has several medications ordered to treat the diagnosed condition. The client is refusing the medications, stating that the benefits do not outweigh the side effects. What is the nurse's best response to this situation?

Consult with the prescribing physician.

A 9-year-old child presents to a school nurse and reports arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate?

Contact the authorities immediately.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention?

Control the pain and support breathing and oxygenation.

The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse?

Document the adolescent's choice and offer to discuss feelings about the medication. EXPLANATION: The client has the right to choose whether to take the medication. The nurse should try to determine the reason for the adolescent not wanting the medication other than choice (e.g., side effects, fear of falling asleep and not waking). The other options do not support the autonomy of the adolescent to make an informed decision.

The emergency department nurse is admitting a client who does not speak English. The client is accompanied by the client's adult son, who does speak English. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain because of the language barrier. How should the nurse best communicate with the client?

Enlist the help of a hospital interpreter; ask the client's son to translate if none is readily available.

A nurse is caring for a preschooler who sustained deep partial-thickness burns on the hands as a result of touching a hot pot on the stove. What is most important for the nurse to consider in discharge teaching?

Include the child in the teaching process.

During a meeting with nurse managers from the crisis intake unit, acute mental health unit, and mental health long-term care unit, the hospital risk manager says, "Approximately 57% of our client safety problems can be directly attributed to poor handoffs." What solution might the nurse managers implement to improve these statistics?

Initiate a template of transfer information to be communicated when a client is transferred from one care setting to another.

A nurse is caring for an 8-year-old female with multiple, chronic urinary tract infections. While the nurse helps the child's parent provide morning care, the child states, "My uncle doesn't clean me that way." The parent becomes visibly upset and gives the girl a stern warning not to discuss the matter. What is the priority action for the nurse?

Notify the nursing supervisor and the authorities of the possibility of abuse.

The nurse is working on a hospital's birthing unit when a primigravid client in active labor is to receive morphine. As the nurse enters the medication room, the nurse observes a coworker slipping a vial of morphine into the side pocket of the uniform. Which action would be most appropriate?

Notify the supervisor of the unit.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma.

A hospitalized 5-year-old child cries daily, is fearful and apprehensive about health care procedures, and does not want to cooperate with the nurse. What is the nurse's best action?

Offer verbal education and client/family teaching on coping skills. EXPLANATION: Fear and anxiety are normal reactions in the hospitalized pediatric client, and providing verbal education on coping skills would be the best initial intervention, and it is cost-effective. Outpatient counseling could be needed, but it would not be an initial intervention and would be more costly. A mental health consult would not be indicated as an initial intervention for a normal reaction to the stress of a hospitalization, and would be more appropriate for an acute mental health problem. Ignoring the situation is not the best intervention, as the client and family need assistance coping with the hospitalization.

A client presents to the nurses' station with symptoms of a panic attack, including shortness of breath, dizziness, trembling, and nausea. Which is the nurse's first intervention?

Stay with the client, and offer support.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately?

The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization.

The nurse is providing care to several clients. In which situation would the nurse be able to accept a verbal order from the healthcare provider?

The client is hemorrhaging from a surgical wound.

A client with a history of major depression established a psychiatric advance directive that was deemed legally valid. The directive specified that the client did not want electroconvulsive therapy (ECT) at any time. The client is legally competent and has expressed a renewed interest in trying ECT. The nurse should anticipate what event?

The client may revoke or amend the terms of the advance directive.

A client was admitted to the coronary care unit (CCU) two days ago with an acute myocardial infarction. Which action would breach client confidentiality?

The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved?

The entry should include clearer descriptions of the client's mood and behavior. EXPLANATION: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

The nurse is reconciling the medications with a client who is being discharged. Which information indicates there is a "discrepancy"?

There is lack of congruence between a client's home medication list and current medication prescriptions.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. EXPLANATION: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.

A nurse working in the triage area of an emergency department sees several pediatric clients arrive simultaneously. Which client should be treated first?

a 2-year-old child with stridorous breath sounds, sitting up and drooling

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first?

a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours EXPLANATION: Urine output should be at least 500 mL in 24 hours (20 mL/h); this client's output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs.

The nurse is making client rounds following shift report. Which client should the nurse assess first?

a 75-year-old man with metastatic prostate cancer with a pathologic fracture of the femur who is in pain

A client comes to the emergency department reporting severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?

acute pain EXPLANATION: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of acute pain takes highest priority. Diagnoses of risk for infection and impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of imbalanced nutrition: Less than body requirements isn't pertinent at this time.

The nurse is working as charge nurse on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention?

administering oral tetracycline with milk to a client with cellulitis

The nurse is working as charge nurse on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention?

administering oral tetracycline with milk to a client with cellulitis EXPLANATION: Dairy products inhibit the absorption of tetracycline, decreasing the effectiveness of the antibiotic. All the other activities are not appropriate, but would not cause as much potential harm as the administration of tetracycline with milk. Anaerobic bacteria would not likely grow in a superficial wound. Herpes zoster vaccine is recommended for clients who are older adults (60 years or older). Pressure garments are used after graft wounds heal and during the rehabilitation phase after a burn injury, and should be discussed when the client is ready for rehabilitation, not when the client is admitted.

The nurse can be an important advocate for the client who is considering an alternative method of cancer treatment. Which statement best demonstrates the nurse as client advocate? The nurse will:

allow the client to make health care choices but will assist in ensuring the client is fully informed when making those decisions.

The nurse manager has noticed a sharp increase in medication errors associated with IV antibiotic administration over the past 2 months. The nurse manager should discuss the situation with each nurse involved and then:

ask them to attend in-service training for administration of IV medications.

A client in an acute care mental health program refuses a morning dose of an oral antipsychotic medication and believes it contains poison. The nurse should respond by taking which action?

consulting with the physician about a care plan.

A nurse is frustrated by inability to make much progress establishing a therapeutic relationship with a client with bipolar disorder. The nurse's most professional response would be to:

discuss the situation with a more experienced peer. EXPLANATION: A collaborative approach is always a better way to address challenging situations; additional input may provide insight to help the nurse provide more effective client care. Asking to be reassigned and suggesting that another nurse might provide more effective care are avoidant responses that do not address the underlying issues. At this time, there is no indication that a medication reevaluation is necessary.

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?

ending each entry with a signature and title

The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older adult clients?

fears and conflicts about aging EXPLANATION: The most common reason for a nurse's discomfort with older adult clients is that the nurse has not conducted a self-examination of fears and conflicts about aging. Until nurses resolve their fears, it is unlikely that they will feel comfortable with older adult clients. A dislike of physical contact with older people, a desire to be surrounded by beauty and youth, and recent experiences with a parent's older adult friends are possible explanations, but not common or likely.

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department?

gonorrhea

A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?

increasing fluid intake to 3 L/day

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff?

logging off a computer containing client information EXPLANATION: All members of the healthcare team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and client education aren't within the scope of practice of the clerical support staff.

The nurse instructs the unlicensed assistive personnel (UAP) on how to care for a client with chest tubes that are connected to water-seal drainage. The nurse should instruct the UAP to:

mark the time and amount of drainage on the collection container.

A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is starting the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which client?

middle-aged stable client with bladder cancer awaiting surgery

The nurse makes initial rounds for the clients. Five medications are scheduled for administration at the same time to five different clients. Which medication should the nurse administer first after initial rounds?

morphine sulfate to a client with a myocardial infarction reporting chest pain

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)?

obtaining a wound culture during a dressing change

In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?

orders for antibiotics EXPLANATION: Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.

A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review?

reducing cholesterol levels, increasing activity levels progressively, and coping strategies

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair

The charge nurse in an acute care setting assigns a client who is on one-on-one suicide precautions to a psychiatric aide. This assignment is considered:

reasonable nursing practice because one-on-one requires the total attention of a staff member.

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, "He is rude. His patients always end up with infections." The nurse is at risk of being accused of what?

slander

The nurse is caring for an older adult man who walks 2 miles every morning. The nurse notes that during his morning walk, he called his child and stated that he thought that he was having a heart attack. Which symptom, identified by the client, is the most common and consistent with that of a heart attack (myocardial infarction)?

substernal pain

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

supporting the client's emotional status EXPLANATION: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The parent does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his parent, the nurse should consider that:

these circumstances may allow the child to translate.

The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up?

weekly visits by a community health nurse

In which situation can a client's confidentiality be breached legally?

when a client near discharge is threatening to harm an ex-partner EXPLANATION: Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Student papers should not contain identifying information. Release of information is made directly to the client's insurance company, not to the employer.