PN Management Online Practice 2020 A
A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. The client reports falling while trying to go to the restroom. Which of the following actions should the nurse take first?
Check the client for injuries
A nurse is assisting with the discharge planning for a client. Which of the following actins should the nurse plan to take?
Include community resource phone numbers with the client's discharge instructions
A nurse is contributing to the plan of care for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following members of the inter-professional health care team should the nurse consult to assist the client with glucose management?
Registered dietitian
A charge nurse in a long-term care facility is reviewing message boards in various client rooms. Which of the following information should the charge nurse request one of the nurses remove from a client's board?
"Hospice nurse visit at 1600"
A nurse is reinforcing discharge teaching with a client who is 2 days postpartum. The client expresses concern about a lack of family support and limited financial resources. Which of the following responses should the nurse make?
"How do you feel about discussing your concerns with a social worker?"
A nurse is reinforcing teaching about home safety with an older adult client. Which of the following statements by the client indicates an understanding of the teaching?
"I will paint the edge of each of my entry steps a different color"
A nurse in a long-term care facility is assisting with the admission of a client. The client tells the nurse, "I don't need advance directives because my partner knows my wishes." Which of the following response should the nurse make?
"I will provide you with written information about advance directives"
A nurse is assisting with the care of a client who has terminal cancer and is receiving chemotherapy. The client tells the nurse that they are only continuing treatment for their family's sake. Which of the following responses should the nurse make?
"Let's talk about your reasons for continuing treatment"
A nurse is reinforcing teaching with a newly licensed nurse about the role of the nurse in informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"My signature on the consent form indicates the client gave consent for the procedure voluntarily"
A charge nurse is talking with two assistive personnel (AP) who are angry about the order in which lunch breaks are scheduled on the unit. Which of the following statements by the charge nurse demonstrates the use of compromise?
"You can take turns going to lunch first every other week"
A nurse in a long-term care facility is caring for a client who has heart failure and is refusing to take a new medication. Which of the following responses should the nurse make?
"You have the right to refuse the medication"
A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of the following events should the nurse document as a variance?
The client has a circular area of non-blanchable redness on their left heel
A nurse enters a client's room at the beginning of a shift. Which of the following findings requires intervention by the nurse?
A capped bottle of sterile water that was opened 36 hr ago
A nurse is discussing the condition of several clients with an assistive personnel (AP) prior to routine vital sign measurement. The nurse should plan to measure vital signs for which of the following clients rather than delegating this task to the AP?
A client who has a new onset atrial fibrillation and reports lightheadedness
A nurse is assisting with the evacuation of clients who have been triaged following a mass casualty event. Which of the following clients should the nurse recommend for first transport to the health care facility?
A client who has paradoxical respirations and has been assigned a red tag
A charge nurse is evaluating the documentation of care for four clients by a newly licensed nurse. Which of the following entries requires intervention by the charge nurse?
Administered 10.0 u of insulin SQ to client for elevated glucose level
A nurse on a pediatric unit is assisting with the care of a group of clients. Which of the following clients would benefit most from an inter-professional care conference?
An infant who has cystic fibrosis and is continuing to lose weight
A nurse is contributing to the plan of care for a client who is newly admitted to a rehabilitation facility. Which of the following actions should the nurse take first?
Ask the client to identify their goals for recovery
A nurse is contributing to the plan of care for a client who has a prescription for a 24 hr urine specimen. Which of the following interventions should the nurse plan to include? (select all that apply)
Begin the timed collection by discarding the first specimen Post the times for urine collection above the toilet in the client's bathroom Obtain a clean specimen collection container for use during the test
A charge nurse is a member of the resource management team for a skilled care facility. Which of the following actions should the charge nurse implement to ensure the facility is providing cost-effective wound care for clients?
Develop a spreadsheet to prepare a budget for wound care supplies
A nurse enters the room of a client who is sleeping and observes sparks coming from a frayed bed plug in the client's electrical outlet. Which of the following actions should the nurse take first?
Evacuate the client
A nurse is assisting with the care of a client who was admitted with deep-vein thrombosis. The client has decided to leave against medical advice. Which of the following actions should the nurse take?
Explain to the client the risk involved in leaving the facility
A home health nurse is reinforcing teaching about the effects of carbon monoxide poisoning. Which of the following manifestations should the nurse include?
Headaches
A nurse is monitoring an assistive personnel (AP) who is calculating I&O for a postoperative client. The client has a portable would bulb suction device and an indwelling urinary catheter. The nurse should recognize that the client's output is calculated and recorded correctly when the AP performs which of the following actions?
Includes emesis and wound drainage in the total recorded output
A nurse overhears two assistive personnel (AP) discussing the details of a client's diagnosis and treatment plan in the hospital cafeteria. Which of the following actions should the nurse take?
Inform the AP that the conversation violates the client's confidentiality
A nurse is caring for an adolescent who requires a blood transfusion. The client's parents will not consent to the transfusion due to religious beliefs. Which of the following actions should the nurse take?
Inform the charge nurse and recommend that social services be contacted
A nurse observes an assistive personnel (AP) taking a picture of a client who has not given consent. The nurse should identify that the AP has committed which of the following torts?
Invasion of privacy
A nurse has just received change-of-shift report for a group of clients. Which of the following actions should the nurse take to manage their time effectively?
Keep a client to-do list for the day
A nurse is discussing delivery models of care with a group of newly licensed nurses. Which of the following should the nurse include as an example of the functional nursing model of care?
Nurses are assigned specific tasks to perform for each of the clients
A nurse is assisting with the care of a client who I scheduled for surgery. Which of the following actions should the nurse take as part of the informed consent process?
Obtain informed consent from the client
A nurse is assigned to care for a client who is in isolation. Which of the following actions should the nurse take to manage time effectively while caring for this client?
Organize care tasks into groups that can be performed at one time
A nurse is contributing to the development of a fall prevention policy for clients who have dementia. Which of the following sources of information should the nurse identify as the primary guideline for the creation of the policy?
Peer-reviewed nursing journals
A nurse is monitoring a client who is receiving IV fluids via an infusion pump and notes the pump is malfunctioning. Which of the following actions should the nurse take?
Place a tag on the IV pump
A nurse is preparing to delegate assignments after receiving change-of-shift report. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
Provide postmortem care
A nurse is contributing to the plan of care for a client who has acute hypothyroidism. Which of the following interventions should the nurse include in the plan?
Provide the client with a reduced-calorie diet
A nurse on a facility's performance improvement team is assisting to develop practice guidelines for performing bladder scans. Which of the following actions should the nurse take prior to developing a policy and procedure for this task?
Review evidence-based practice data related to bladder scanner use
A nurse is preparing to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse plan to take? (Select all that apply)
Select an interpreter who is the same gender as the client Ensure interpreters provided by the facility have knowledge of medical terminology Choose an interpreter from the same ethnic background as the client
A nurse in a long-term care facility is caring for a client who had a stroke 1 week ago. The client is experiencing left-sided weakness, difficulty swallowing, drooping of the mouth, inarticulate speech, and memory loss. Which of the following referrals is the priority for the nurse to make?
Speech therapy
A charge nurse in a long-term care facility is monitoring the activities of an assistive personnel (AP). Which of the following actions by the AP indicates that the charge nurse should intervene?
Stands with feet close together while transferring a client from the bed to a chair
A nurse arrives for their shift and is assigned more clients than they feel is safe. The charge nurse states there are no other options due to a shortage in nursing staff. Which of the following actions should the nurse take first?
Submit a written complaint to the nursing supervisor
A nurse is caring for a client who is received a skin tear during a routine dressing change. After completing an incident report, which of the following actions should the nurse take?
Submit the incident report to the nurse manager for review
A nurse is assisting with the discharge of a client who has a new permanent colostomy. The client expresses concern about learning to care for the appliance, affording colostomy supplies, and obtaining supplies discretely. Which of the following actions should the nurse take? (select all that apply)
Suggest that the client join an stony support group Arrange a follow-up appointment with an enterostomal therapy nurse Provide the client with the name and number of an ostomy supply delivery service Request a social work referral for the client to discuss financial concerns
A nurse is preparing to care for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse plan to take first?
Take the client's vital signs
A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following client actions should the nurse recommend transfer to an acute care facility?
The client develops command hallucinations
A nurse is participating in the unit's performance improvement program. The nurse should recognize that which of the following is a quality indicator?
The facility-wide fall injury rate for the previous quarter is 3%
A nurse in a skilled nursing facility is caring for a group of clients. Which of the following actions demonstrates the nurse's role as client advocate?
The nurse assists a client in communicating end of life decisions to the provider
A community health nurse is reinforcing teaching with a group of parents about home safety for children of various age groups. Which of the following information should the nurse plan to include?
The supine position is the safest for sleeping infants
A nurse is participating on a committee that is revising the facility's policies and procedures for infection control. Which of the following instructions should the nurse recommend including in the facility's infection control manual?
Use a 1:10 bleach solution to clean blood spills
A nurse is preparing to document client care in the electronic health record for a client who is postoperative. which of the following should the nurse include in the documentation?
a treatment that was refused by the client
A nurse is reinforcing teaching with a newly licensed nurse about the administration of an opioid pain medication. Which of the following instructions should the nurse include?
have a second nurse witness disposal of the unused portion of the client's medication
